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PLATE I. 



Callous tortuous stricture of the deep urethra. 



STRICTURE 



OF* 



THE URETHRA 




G. FRANK LYDSTON, M.D. 

PROFESSOR OF THE SURGICAL DISEASES OF THE GENITO-URINARY ORGANS AND 
SYPHILOLOGY IN THE CHICAGO COLLEGE OF PHYSICIANS AND SURGEONS; 
ATTENDING SURGEON TO COOK COUNTY HOSPITAL ; FELLOW OF 
THE CHICAGO ACADEMY OF MEDICINE AND OF THE 
SOUTHERN SURGICAL AND GYNAECOLOG- 
ICAL ASSOCIATION, ETC. » 



WITH SEVEN FULL PAGE PLATES AND EIGHTY-FIVE WOOD CUTS. 



CHICAGO: ^J j 

THE W. T. KEENER COMPANY 2- 5*^7 7 

£)G Washington Street 
1 ?93 




w 

u 



^■4 



COPYRIGHTHED, 1893, BY 

THE W. T. KEENER COMPANY. 



TO THE MEMORY OF 

WILLIAM H. VAN BUREN, A.M., M.D., L.L.D. 

Formerly professor of surgery in the bellevue hospital 

medical college, surgeon to charity hospital, 

one of the pioneers in genito-urin- 

ary surgery in america, 

THIS VOLUME 

IS RESPECTFULLY DEDICATED BY HIS GRATEFUL PUPIL 
AND HOSPITAL INTERNE, 



THE AUTHOR. 



1 



PREFACE. 



This volume comprises essentially a series of class- 
room lectures upon urethral stricture. No attempt has 
been made to fill the work with rubbish from the liter- 
ary dead lumber room, or to introduce innovations, 
more startling and misguiding than practical. The 
genito-urinary specialist, or to use a more modern 
term, the andrologist, may find that a great deal of 
old straw has been threshed over, but the general prac- 
tictioner and student — for whom the book is especially 
designed — may find a few grains of practicality not 
hitherto presented in a readily assimilable form. Re- 
garding the illustrations in this monograph, a fashion 
prevailing in certain quarters has been departed from, 
due credit being given, as far as possible, to the 
authors from whom they have been taken. Whether 
or not there is room for this addition to an already 
over-burdened special surgical literature, remains to be 
answered in the future by the publishers. 

Opera House Block. 
Chicago, May ist, 1893. 



TABLE OF CONTENTS. 



Chapter I. 

PAGE 

Anatomy of the Urethra 3-26 

Chapter II. 

Normal curve of the Urethra. Instrumentation of the 

Urethra 2 7-47 

Chapter III. 
Stricture of the Urethra. Definition and Varieties. 

Spasmodic, Congestive and Inflammatory Stricture. 48-71 

Chapter IV. 

Organic Stricture. Traumatic Stricture. Urethral 
Stricture in the Female. Congenital Stricture. 
Varieties of Organic Stricture. Location of Strict- 
ure 72-89 

Chapter V. 
Pathological Localization of Stricture 90-100 

Chapter VI. 
Morbid Anatomy of Stricture 102-109 

Chapter VII. 

Causes of Stricture. Symptoms of Stricture. Diagno- 
sis of Stricture. Prognosis of Stricture. 110-133 

Chapter VIII. 
Treatment of Stricture. General Management. Selec- 
tion of Method. Treatment by Caustics. Treat- 
ment of Stricture of the Meatus. Treatment of 
Stricture of the Penile Urethra. Treatment of 

Stricture of the Deep Urethra 135-163 

7 



CONTENTS. VIII 

Chapter IX. 
Systematic Treatment of Stricture by Dilatation 105— 1 Ti) 

Chapter X. 

Untoward Effects of Dilatation. Urethral or Urine 
Fever. Nervous Manifestations Following Dilat- 
ation. Hemorrhages and False Passages from 
Dilatation 180-212 

Chapter XI. 

Operative Treatment of Stricture. Divulsion. Inter- 
Urethrotomy. Cases Showing Permanency of re- 
sults' in Urethrotomy. External Urethrotomy 
Subcutaneous Urethrotomy , 21 3-260 

Chapter XII. 
Electrolysis of Urethral Stricture 2G1-275 

Chapter XIII. 
Complications and Secondary Results of Stricture. 
False Passages. Retention of Urine. Infiltration 
of Urine. Urethral Fistula. Prostatic Hypertro- 
phy. Inflammation of the Seminal Vesicles. Cys- 
titis. Impotence 270—327 



LIST OF ILLUSTRATIONS. 



PLATES. 

Plate I.— Callous tortuous stricture of the deep urethra. Frontispiece. 

Plate II.— Multiple stricture Facing page 72 

Plate III.— Old stricture of pendulous urethra, showing diverticula and bands 

• Facing page 90' 

Plate IV.— Extremely contracted stricture in a young patient Facing page 109' 

Plate V.— Granular Urethritis Facing page 1 79 

Plate VI. — Formation of false passage in stricture Facing page 276 

Plate VII.— Results of peri urethral suppuration with pocket and sinus 

formation Facing page 304. 

PAGE. 

Fig. 1.— Anatomical relations of the urethra, prostate, and bladder, shown i i 
vertical section. This illustration shows the relative curve of the urethra 
in its flaccid condition and in the position proper for instrumentation. 

—(After Gray.) 5 

Fig. 2. — Anatomical divisions of the urethra and their relations to Cowper's 

glands, the prostate and bladder.— (A iter Gray.) 7 

Fig. 3 — Section through spongy urethra, showing erectile tissue and relation 

of urethra to body of penis. — (After Cruveilhier.) 9 

Sections of the penis illustrating the relations of the urethra to the corpus 
spongiosum at various points from the glans to the bulbo-membranous 

junction — (After Weir.) lO 

Fig. 4-.— Section made m. 0.010 below base of glans lO 

Fig. 5.— " " m. 0.035 " " " lO 

Fig. 6.— " " m. 0.065 " " " 10 

Fig. 7. 1 Sections made from anterior boundary of bulbous portion almost to 

Fig. 9 [ beginning of prostatic urethra lO 

a. b — Vertical sections of spongy bod3 r showing relations of the urethra to 

the erectile tissue lO 

Fig. 10. — Vertical section of the urethra at the fossa navicularis. —(After 

Cruveilhier 11 

Fig. 11. — Section through prostatic urethra.— (After Cruveilhier.) 13 

Fig. 12.— Showing lacuna magna. A. Spongy Urethra. B. Fossa Navicu- 
laris. C. Probe separating valve-like fold from roof of Lacuna Magna. 

D. Lacuna Magna. — (Alter Bumstead and Taylor.) 15 

Fl«*. 13. — Showing deep layer of superficial fascia (Buck's fascia). — {After Gray). 18 

Fig. 14. — Buck's fascia reflected, showing structures within its layers 19 

Fig. 15. — Buck's fascia, showing body of penis dissected up, exposing cavity 

comprised by the fascia. — (After Guidon Buck) 2(> 

Fig. 16. — Showing deep perineal fascia (Triangular ligament), with its an- 
terior layer removed. — (After Gray) 212 

Fig. 17. — Diagrammatic section of perineum showing arrangement of the 

triangular ligament (deep perineal fascia). — (After Tillaux) 23 

Fig. 18.— Deep dissection of perineum showing recttim turned aside and re- 
lations of prostate, seminal vesicles, bulb and membranous urethra. — (After 
Gray ) ~ J 



2 ' LIST OF ILLUSTRATIONS. 

Fig. 19. — Showing relations of bulb, membranous urethra and prostate to 

the deep perineal fascia or triangular ligament. — (After Gray.) 26 

Fig. 20. — Showing proper curve for urethral instruments 28 

Fig'. 21. — Showing comparative curves of urethral instruments 29 

Figs. 22 and 23. — Scale plates for measuring instruments 38 

Fig. 24. — Showing proper angle of point of instruments in relation to shaft 39 

Figs. 25 to 30. — Showing method of urethral instrumentation 42-45 

Figs. 31, 32 and 33. — Showing relation of the bougie a boule to points of con- 
traction 46 

Fig. 34. — Linear stricture in the anterior urethra. — (After Voillemier .) 77 

Fig. 35. — Irregular stricture showing flaps, bands and bridles. — (After Dittel).. 78 

Fig. 36. — Annular stricture. — (After Dittel.) 79 

Fig. 37. — Case of multiple stricture. — (After Otis.) 81 

Figs. 38 and 39. — Casts of the urethra. — (After Sands.) 94. 

Fig. 40. — Extreme results of organic stricture. — (After Keyes.) 105 

Fig. 41. — Results of urinarv obstruction of long standing. — (After Crosse.) 106 

Fig. 42. — Hypertrophy and contraction of the bladder from stricture 106 

Fig. 43. — Extreme results of long standing stricture. — (After Morris.) 107 

" 44. — Otis' urethameter 120 

Figs. 45 and 46. — Bulb sounds and their modus operandi 121 

Fig. 47. — Weiss' bougie a boule 122 

" 48. — Guyon's bougie a boule 122 

*' 4. 9. — Piffard's meatometer 123 

*' 50. — Civi.tle's meatatome 123 

*' 51. — Piffard's meatatome 123 

"" 52. —Screw tipped guides 166 

" 53. — Gouley's whalebone guides 166 

" 54. — Banks' whalebone bougies 167 

41 55. — French olivary bougies 168 

"" 56. — Van Buren's steel sound 169 

" 57. — Otis' endoscopic tube 177 

'" 58. — Brown's urethral speculum 177 

" 59. — Klotz's endoscope 177 

" 60. — Weir's meatoscope 177 

" 61. — Method of injection of deep urethra. — (After Finger) 178 

'" 62. — Holt's divulsor 214 

" 63. — Thompson's divulsor 214 

" 64. — Gouley's rapid dilator 21 5 

" 65. — Gouley's dilating urethrotome 218 

" 66. — Maissonneuve's urethrotome 218 

" 67. — Civiale's urethrotome 219 

" ' 68. — Otis' straight urethrotome * 219 

" 69. — Otis' curved urethrotome 220 

" 70. — Otis' diagonal urethrotome 225 

" 71. — Case showing remote result of internal urethrotomy 243 

'" 72. — Wheelhouse's operation of perineal section 252 

" 73. — Method of using electrolysis in stricture — (Prince.) 264 

"" 74. — Potain's aspirator 282 

*' 75.— Showing proper points for rectal and suprapubic puncture. — (After 

Erichsen.) 283 

Fig. 76. — Cock's operation of tapping the prostate. . . 285 

' ' 77. — Extensive fistulae from stricture 307 

Figs. 78 to 81. — Szymanowski's operation for urethral fistula 316 

" 82 to 83. — Nelaton's operation for penile fistula 319 

" 84 to 85. — Clark's operation for penile fistula 319 



CHAPTER I. 



ANATOMY OF THE URETHRA. 

A knowledge of the anatomy of the male urethra is 
of the greatest importance with reference to the study 
and treatment o^ urethral stricture, its results and com- 
plications, hence it may not be unprofitable to review it 
as a preliminary to the consideration of the latter sub- 
ject. 

The male urethra, unlike that of the female, sub- 
serves two important functions : that of urination, which 
function the urethra of the male and female possess in 
common, and that of generation, which is peculiar to 
the male canal. As far as its urinary function is con- 
cerned, the urethra is of secondary importance, inas- 
much as it is by no means necessary to micturition; it is, 
however, of the utmost importance as a carrier of 
semen. Upon the deposition of the semen at the proper 
point in the vagina, impregnation chiefly depends, — as 
far as the seminal elements are concerned. Obviously, 
the conveyance of the semen to the proper point depends 
upon the functional integrity of the urethra. In con- 
sidering the diseases of the urethra and their direct and 
remote results, both the urinary and sexual functions 
of the canal should be taken into consideration. 

The urethra extends from the anterior extremity of 
the glans penis to the neck of the bladder. In its qui- 
escent and flaccid condition it presents two distinct 
curves, one of which corresponds to the pendulous por- 
tion of the canal and curves from about the situation of 
the triangular ligament, first upward and forward and 
then downward, with its concavity below, and the 
other representing the fixed portion directed from the 
triangular ligament first downward and then upward 



4 ANATOMY OF THE URETHRA. 

with its concavity above. When in the erect state, the 
anterior curve is obliterated and the canal becomes 
straight from the meatus urinarius almost to the open- 
ing in the triangular ligament. 

The length of the urethra as given by most anato- 
mists is from eight to nine inches, but the greatest dis- 
crepancy exists upon this particular point. A table 
showing the estimates of various clinical observers 
would show an especially marked variance of opinion. 
A difference of twenty or thirty per cent in the estimated 
measurements of equally competent observers is not 
unusual, and is hardly to be wondered at. Itisprobable 
that no two observers can possibly obtain precisely simi- 
lar conditions for measurement. The penis varies in 
size not only intrinsically in different subjects, but there 
is the greatest imaginable variation in the same subject 
under different conditions. Some patients undergo 
manipulations of the sexual organs with the greatest 
equanimity, while in others the organs are either reflexly 
excited or emotionally inhibited as to circulation. The 
result is a decidedly fluctuating standard of urethral 
measurement. Much depends upon the method of 
measurement. One surgeon will pull the organ tensely 
upward on the shaft of the instrument, while another 
will allow it to remain in its normal position; others 
again, will crowd the organ down towards the perineum 
with little or no attempt at support by traction or other- 
wise. The average length of the urethra as de- 
termined upon a series of cadavers, is obviously an 
unfair criterion for practical deductions, as there are 
none of the conditions present,— save of course, varia- 
tions of manipulation, — which prevail during life. The 
length of time elapsing after death before the measure- 
ments are made, probably has much to do with the ac- 
curacy of the result. 

From what has been said, it will be observed that 
each urethra is a law unto itself as far as its length is 



LENGTH OF THE URETHRA. 



concerned. The length of a particular urethra may be 
said to be the distance from the meatus traversed by 
the catheter before the urine begins to flow, the penis 
being flaccid and placed upon a degree of tension 
merely sufficient to afford adequate support during in- 
strumentation. Due allowance should be made for 
sexual excitation or emotional inhibition. 

The same arguments are pertinent with reference 
to the determination of the average calibre of the 




Pre»u*+ 



Anatomical relations of ths urethra, prostate, and uladder, shown in 
vertical section. This illustration shows the relative curve of the urethra in 
its flaccid condition and in t!u position proper fjr instrumentation. — {After 
Gray.) 

urethra. This is a point too often neglected by the 
surgeon. 

In discussing the anatomy of the urethra we must 
nolens volens accept the statement of Gray and others, 



6 ANATOMY OF THE URETHRA. 

that the adult urethra averages from eight to nine inches 
in length. 

The externa] curve of the urethra is not of great 
importance with relation to instrumentation, as it can be 
adapted to almost any form of instrument. It is differ- 
ent, however, with the posterior or deep curve which is 
relatively fixed; it cannot be said to be constantly fixed, 
because as is well known, straight instruments can be 
introduced into the bladder. The fixed urethral curve 
is not uniform, but varies widely with the period of life 
and the condition of the prostate body. It is compar- 
atively short and sharp in the child, much longer and 
less abrupt in the adult, these characteristics increasing 
in prominence greatly as the subject grows older. In 
prostatic enlargments the curve becomes so greatly elon- 
gated as to necessitate considerable modification of 
instruments and manipulations for entering the blad- 
der. This point is of the greatest practical importance 
to the genito-urinary surgeon. 

DIVISIONS OF THE URETHRA. 

The urethra is divided for description into the 
spongy, membranous and prostatic portions. Of these 
portions the spongy is about six inches, the membran- 
ous three-fourths of an inch, and the prostatic one inch 
and a quarter in length. 

Meatus urinarius'. The urethra begins in front at 
the meatus urinarius, an opening which varies greatly as 
regards its size and dilatability. The degree of dilata- 
bility depends mainly upon the consistency of the tissue 
at the inferior commissure of the meatus. In some cases 
this consists of a thin membranous septum which dis- 
tends readily and admits a much larger instrument than 
would be supposed from the calibre of the meatus. In 
other cases, although this tissue is quite thin there ap- 
pears to be when put upon the stretch, a tense fibrous 
cord about the meatal circumference which may be ob- 



THE MEATUS UR1NARIUS. 



served as a thin white band which tightly grasps the in- 
strument. Attempts at stretching this band only re- 
sults in reflex resentment, so to speak, against the pas- 



Con-pet's dund. 



OrlfitrR of rtitctt, 
Oj Confers Glunds 




FIG. 2. 



Anatomical divisions of the urethra and their relations to Cowpers 
glands, the prostate and bladder.— {After Gray.) 

sage of the instrument by the urethral muscles. In 
some cases the lower commissure of the meatus is 
formed by a quite thick septum of spongy tissue, the 



8 ANATOMY OF THE URETHRA. 

post-meatal pouch being almost absent. Obviously, it is 
in the latter variety of conformation that we experience 
most difficulty in meatotomy, from cicatricial con- 
traction. 

In quite a large proportion of cases the meatus is 
fairly dilatable but the urethra is contracted just within 
the orifice. This contraction constitutes a quite fre- 
quent form of congenital stricture of the meatus. In 
some cases this congenital narrowing is from one-fourth 
to one-half an inch from the external orifice. These 
points of narrowing should be taken into consideration 
in the performance of meatotomy. Very frequently the 
meatus is incised and the contraction which is causing 
the trouble for which the operation is indicated is com- 
pletely overlooked, with a consequent failure to give re- 
lief to the symptoms. Occasional cases are seen in 
which the meatus is bifid below. Others again, pre- 
sent a fold of quasi-mucous membrane passing trans- 
versely across the superior angle of the meatus just with- 
in the commissure. 

In certain cases of hypospadias the urethra opens 
on the under surface of the glans or at some point in 
the floor of the spongy urethra. In such cases the orifice 
is small and pouting, and is very easily irritated. When 
a gonorrhoea or stricture exists in such cases the situa- 
tion is annoying in the extreme. 

Spongy Urethra'. The spongy, pendulous or penile 
urethra is the longest part of the canal and extends from 
the meatus urinarius to the triangular ligament. This 
portion of the urethra tunnels the corpus spongiosum. 
It is about six inches in length and begins posteriorly 
about an inch below the pubic symphysis, at which point 
it traverses the triangular ligament. In this situation 
the corpus spongiosum presents a bulbous expansion, -the 
bulb of the corpus spongiosum, — the urethra being cor- 
respondingly dilated, — the bulbous urethra. This point 
of dilatation is to be remembered as the locality in which 



THE SPONGY URETHRA. 9 

chronic inflamation is most likely to become localized, 
a matter of the utmost importance in the consideration 
of chronic urethritis and stricture. A stricture of the 
deep urethra is quite apt to be associated with a chronic 
granular urethritis at this point. It is in this region 
also that pouching of the urethra is most apt to occur as 
a consequence of anterior obstruction or of bungling at- 
tempts at instrumentation of stricture located behind 
the bulb. According to Gray and others, the spongy 
urethra is of uniform size in the body of the penis, but 
while this may be true from the post mortem standpoint 
of the anatomist, it is rarely so from that of the clinician. 
Few urethrae, indeed, will be found in which the spongy 
urethra does not show a variation of calibre at differ- 
ent points. This variation may be relative and not 
real, and due to a variation of dilatability under pres- 
sure, but it is none the less a palpable condition under 
the hands of the practical surgeon. 




FIG. 3. 

Section through spongy urethra showing erectile tissue and relation of 
urethra to body of penis.— {After Cruvcilhier.) 

Just at the point where the central portion of the 
spongy urethra begins to dilate to form the bulbous 
urethra, the urethra is relatively slightly narrowed, — or 
perhaps more properly speaking, relatively indistensible. 
The same holds true of the anterior extremity where 
the spongy urethra dilates to form its anterior expanded 
extremity, the fossa navicularis. 

The bulbous urethra is the point of exit of the ducts 
of Cowper's glands, structures which occasionally afford 
an annoying complication of urethritis. 



IO 



ANATOMY OF THE URETHRA. 



A cross section of the penis at different points shows 
considerable variation in the relation of the canal to the 
structures composing the penile tissues. A cross sec- 
tion of the glans shows the long diameter of the 
urethra to be from above downward, while posteriorly it 
is either transversely straight or transversely cres- 
centic. 

The following diagramatic sections of the penis at 
different points illustrate this anatomical fact very nicely. 
These were prepared by one of our most conscientious 
and pains-taking American surgeons, Prof. R. F. Weir, 
of New York City. 



FIG. 4. 



FIG. 5. 



FIG. 6. 






FIG. 7' 



FIG. 8. 






Sections of the penis illustrating the relations of the urethra to the cor- 
pus spongiosum at various points from the glans to the buibo-membranous 
junction. — {After Weir.) 

Fig. 4. Section made m. 0.010 below base of glans. 

Fig. 5. " " m. 0.035 " 

Fig. 6. " " m. 0.065 " 

F'.g- 7- ) Sections made from anterior boundary of bulbous portion al- 

£Jg- «• r most to beginning of prostatic urethra. 

a. b. Vertical sections of spongy body showing relations of the urethra 
to the erectile tissue. 

Fossa navicularis: The spongy urethra is consid- 
erably expanded just within the meatus, the expansion 
corresponding in extent to the glans penis and termi- 



THE MEMBRANOUS URETHRA. 



I I 



nating posteriorly by a slight contraction at its junction 
with the main portion of the spongy body. 




FIG. 10. 



Vertical section of the urethra at the fossa navicularis. — {After Cru- 
veilhier. ) 

In this portion of the urethra also there is a tend- 
ency to localization of innamation. Very frequently a 
chronic gleet will depend entirely upon a chronic inna- 
mation in the pouch-like cavity of the fossa navicularis 
just behind the inferior commissure of the meatus. Such 
cases are incurable until meatotomy has been performed, 
thus securing the necessary rest and drainage for the 
affected part. 

Membranous urethra: The membranous urethra 
extends from the anterior layer of the triangular liga- 
ment, at which point it joins the bulb, to the apex of the 
prostate. With the exception of the meatus, it is the 
narrowest portion of the canal. It is necessary to state 
however that this relative narrowness is due to the fact 
that it is a muscular structure and is a veritable sphinc- 
ter, being continuously in a state of tonic contraction. 
Although the narrowest part of the canal under normal 
circumstances, it is capable of more extreme dilatation 
than any other portion of the urethra, with the exception 
of the prostatic. According to P. Delbet it may be di- 
lated to a diameter of 15 m. m. without rupturing, a de- 
gree of distention which could hardly be supported by 
the spongy portion.* 

*P. Delbet, Recherches Anatomiques sur l'urethre. Annales des nial.des org. genito-ur. 
Mar. 1892. 



12 ANATOMY OF THE URETHRA. 

Guyon has observed that in passing instruments of 
very large calibre, rupture of the urethra always occurs 
in the spongy portion.* 

On account of the strong and abundant muscular 
fibres by which it is surrounded, the membranous 
urethra has been termed the muscular region. This 
point is worthy of attention with reference to spasmodic 
obstruction to urination and the passage of instruments 
which so frequently occurs at this point. 

The membranous urethra lies between the fibrous 
layers of the triangular ligament, and measures three- 
fourths of an inch in length upon the roof of the canal. 
Upon the floor, where it is encroached upon by the bulb 
of the corpus spongiosum, it is reduced to one-half an 
inch in length. 

The point at which the membranous urethra enters 
the triangular ligament is situated about one inch below 
the pubic symphysis, the dorsal vein of the penis pierc- 
ing the ligament one-fourth of an inch higher up. It is 
important to remember the relation of the membranous 
urethra to the pubic arch, especially in connection with 
the operation of perineal section. 

The membranous urethra is composed of numerous 
muscular fibres and fibro-elastic tissue, with a thin layer 
of erectile tissue. It is surrounded by the compressor 
urethrae muscle, and is lined by mucous membrane which 
is closely applied to the sublying tissues, areolar tissue 
being very scanty. 

Prostatic Urethra: The prostatic urethra is the larg- 
est portion of the urethra, and is also capable of more 
extreme dilatation than any other division of the canal. 
It is about an inch and a quarter in length, and tunnels 
the upper portion of the prostate body, coming so near 
the upper surface of the latter in some cases that the 
canal is barely covered in above by prostatic tissue. 
The prostatic urethra extends from the neck of the blad- 

*Guyon Op. cit. 



THE PROSTATIC URETHRA. 1 3 

der, — so called, — to the posterior layer of the triangular 
ligament where it joins the membranous portion. It is 
spindle-shaped, being widest in the middle and nar- 
rowest at its junction with the membranous portion. 
From before backward it is widest above, coming to a 
point below, this giving the canal a triangular form on 
transverse section. 

The floor of the prostatic urethra presents for study 
the most important structures of any portion of the 
canal. Disease located in this region is not only apt to 
become extremely chronic and obstinate but may lead 
to very serious complications. 




FIG. II. 



Section through prostatic urethra. S. p. sinus pocularis. D. ejacula- 
tory ducts. — {After Criivcil/iler.) 

Upon the floor of the prostatic urethra is a longi- 
tudinal elevation from eight to ten lines in length, com- 
posed of erectile and muscular tissues.* This is called 
the veru montanum or caput- gallinaginis, (cock's 
comb) . The function of this structure is probably to 
distend during coitus, thereby preventing the backward 
passage of the semen during ejaculation, thus affording 
a counter-pressure which assists in the extrusion of the 
semen in the normal manner. 

An interesting point bearing upon this function is 
related by French writers: Certain Parisian prostitutes 
are said to prevent conception by pressing upon the 
membranous urethra of their partners via the rectum at 
the moment of ejaculation, with the result of forcing the 
semen backwards past the veru montanum into the 
bladder. After frequent repetitions of this performance 

*Kobelt. 



14 ANATOMY OF THE URETHRA. 

the function of this structure is said to be completely 
and permanently inhibited, with the result that the in- 
dividual is ever after sterile and ejaculates his semen 
into his own bladder. 

On each side of the veru montamim is a longitud- 
inal depression, the prostatic sinus, upon the floor of 
which open the orifices of the ducts of the prostatic 
follicles, twenty or thirty in number. Just in front of the 
veru montanum in the median line is a depression, the 
sinus pocularis , otherwise known as the uterus masadinus, 
upon the supposition of its homology with the womb * It 
contains the orifices of numerous small glands and upon 
its margins open the slit shaped apertures of the ejacu- 
latory ducts. 

Glands of the Urethra: The various glandular 
structures of the urethra are of some clinical importance. 
Scattered all along the canal and especially on the floor 
of the spongy portion are numerous glandular follicles, 
the function of which is to furnish mucus for the lubri- 
cation of the urethra. This lubricating action is of 
especial service during the ejaculation of semen. It 
is quite likely also that the mucus thus secreted is of 
value in diluting and increasing the bulk of the semen. 
It is also said that the alkalinity of this mucus is useful 
in neutralizing the acidity of the vaginal secretions 
which would otherwise be inimical to the vitality of the 
spermatozoa. 

These mucous follicles are known as the glands of 
Littre. They open by ducts which directed toward the 
meatus and are known by some authors as the sinuses 
of Morgagni. According to others the true sinuses 
of Morgagni are blind ducts which run parallel with the 
mucus membrane for about half an inch, terminating 
in a cut de sac. Cruveilhier described these ducts or 
sinuses, and stated that he had seen one which was an 
inch in length. These ducts and sinuses become dilated 

* Weber. 



FOLLICLES OF THE URETHRA. 



15 



in conditions of chronic inflamation, and have much to 
do with the perpetuation of gleet. It is my own opinion 
that the products of virulent inflammation may remain 
sealed up in the urethral follicles for an indefinite 
period, and by discharging from time to time, cause ap- 
parently fresh attacks of virulent urethritis. A single 
follicle thus distended may indefinitely prolong urethral 
trouble. 

A point of equal if not greater importance regard- 
ing these follicles is that their ducts may catch the 
points of small instruments in the treatment of stricture. 
Such a lodgment of a fine instrument is often the starting 




Showing lacuna magna. A. Spongy Urethra. B. Fossa Naviculars. 
C Probe separating valve-like fold from roof of Lacuna Magna. D. Lacuna 
Magna..— (After Bumstcad and Taylor.) 

point of a false passage. Atrophy of the follicles and 
distention and tearing up of these ducts and sinuses 
often accounts for the formation of flaps, bands and 
bridles in stricture. 

There is one sinus in the urethra that is of the 
utmost importance. This is quite large, and is located 
upon the roof of the fossa navicularis. It is known as 
the lacuna magna. Its floor is formed by a valvular 



l6 ANATOMY OF THE URETHRA. 

flap of mucous membrane. Instruments are frequently 
caught in this valvule, the obstruction being mistaken 
for stricture. The relation of this peculiar pouch to 
chronic inflammation has already been expatiated 
upon. 

The sinus pocularis is also mentioned as a point at 
which instruments are apt to lodge. I suspect however 
that the importance of this has been overrated. 

Cowpers glands are important accessories to the 
urethra. They are small round bodies lying just be- 
hind the bulb, one on either side, between the layers of 
the triangular ligament. They are lobulated in structure 
and furnish a fluid which is supposed to assist in dilut- 
ing and increasing the bulk of the semen. These glands 
are of pathological importance in urethritis, as they are 
prone to infection with resultant acute inflammation 
and oftimes abscess. 

STRUCTURE OF THE URETHRA. 

The urethra is composed of three coats — mucous, 
muscular and erectile. The mucous coat is a continua- 
tion of the general mucous membrane of the genito- 
urinary tract, and forms the lining of all the ducts open- 
ing into the urethra. This being the case, it is easy to 
understand the extension of infectious or other inflam- 
matory processes to the urethral follicles, Cowper's 
glands, seminal vesicles and testes. The mucous mem- 
brane of the urethra is quite sensitive, — resembling the 
conjunctiva in this respect. It is of a light pinkish color 
in its normal condition but becomes darker and loses its 
gloss in conditions of inflammation. The epithelium of 
the urethral mucosa is of the pavement variety immedi- 
ately behind the meatus, elsewhere it is of the colum- 
nar variety. The areolar tissue beneath the mucous 
membrane is very scanty. A peri-urethritis therefore 
means inflammation of the areolar and erectile tissue 
outside of the tube. The mucous coat of the urethra is 



STRUCTURE OF THE URETHRA. I 7 

composed of two layers, an external longitudinal and in- 
ternal circular. These fibres are of the involuntary vari- 
ety and bear an important relation to stricture. They 
are interspersed with fibro-elastic and fibro-connective 
tissue. It is the relative proportion of the elastic and 
muscular to the inelastic tissues that determines the de- 
gree of dilatability of any particular point of the canal. 

The erectile tissue is a relatively thin layer which 
has rather less fibrous tissue forming its trabecular than 
have the corpora cavernosa. The varying amount of 
fibrous tissues in the erectile spaces also modifies the 
dilatability of the canal, and in conjunction with a varia- 
tion in the relative proportion of elastic and inelastic 
tissue in the muscular walls, explains. the varying calibre 
of the urethra, both in different subjects and in the 
same subject at different points. 

There are some interesting points regarding the 
form of the urethra that deserve passing mention. The 
urethra is not a rigid and inflexible tube but unless dis- 
tended with fluid or an instrument its walls are closely 
in contact. In the flaccid state, the mucous membrane is 
thrown into longitudinal folds. This point is of the ut- 
most importance from a therapeutical standpoint, for 
no antiseptic or astringent application can be effec- 
tive unless applied while the urethra is, so to speak, un- 
folded. The arrangement of these folds also facilitates 
the formation of stricture when once the deposition of 
plastic material has begun. It is probable that in the 
collapsed and retracted state of the penis, the urethra 
assumes a somewhat spiral or twisted form. Some ten 
years ago I called the attention of my classes to the fact 
that this rifling of the urethra imparts a distinct twist 
to the stream of water escaping from the meatus during 
irrigation of the canal. In some cases the stream will 
twist about the catheter in three or four distinct spirals. 
This occurs not only with the lateral-eyed catheter but 
also with the open ended variety. The fact has re- 



i8 



ANATOMY OF THE URETHRA. 



cently been brought to my notice that an English surgeon 
a few years ago called attention to this rifling of the 
urethra. 




FIG. 13. 

Showing deep layer of superficial fascia (Buck's fascia). — {After Gray.) 

Buck's Fascia: One of the most important struc- 
tures for the consideration of the genito-urinary surgeon 
is the layer of fascia, first accurately described by Dr. 
Gurdon Buck of New York City. The division of the 
fascial investments of the body into special fasciae is, as 
a rule, of questionable value, but an exception is certain- 
ly to be made in this case. Buck's fascia has be- 
come dignified by a special nomenclature by virtue of 
certain peculiar and specialized anatomical relations 
and attachments, that practically, — at least from a 
clinical standpoint, — differentiate it from the general 
layer of superficial fascia covering the body. 

Fig. 13 shows this specialized fascia after re- 
moval of the skin, areolar tissue and superficial layer of 
the superficial fascia. 

Buck's fascia is thin, aponeurotic in structure 
and quite strong. It begins above at the symphysis 



BUCK S FASCIA. 



19 



pubis at the suspensory ligament of the penis, at 
which point, as shown by Richet, it is continuous with 
the general fascia of the abdomen, It passes down- 
ward over the penis and around the corpora cavernosa, 
beneath which it splits into two layers which pass down- 
ward and invest the spongy body. Anteriorly it is at- 
tached to the base of the glans penis. Passing back- 
ward after forming the true sheath of the penis, it be- 




Grf Saoro.SrUlir Lift- 



SupuflcCat Pm ntal Arfr*j 
Suiwrfietal Perineal Arrvm 
Internal jPudtc JVervt 
J nte rnat Pud ' ic A rtt ru 



FIG. 14. 

Buck's Fascia reflected, showing" tha structures within its layers. — 
{Aftet Gray.) 

comes continuous with the dartos muscle covering the 
testes, or better, at the point where it invests the testes, 
the fascia becomes muscular. Passing downward into 
the perineum, the fascia passes backward as far as the 
transversus perinei muscle, at which point it dips down- 
ward and becomes attached to the anterior layer of the 
triangular ligament. It is firmly attached laterally to 
the rami of the pubes and the ascending rami of the 
ischiaas far back as the tuberosities. 

As shown in Fig. 14, Buck's fascia covers in the 
urethral muscles, superficial perineal arteries, veins and 
nerve. 



20 



ANATOMY OF THE URETHRA. 



The peculiar and firm attachments of Buck's fascia 
explains the limitation of urinary and purulent extrava- 
sations into the perineum. The penis, scrotum and per- 
ineum may be infiltrated, but the thighs and the vicin- 
ity of the anus cannot possibly become so save by rup- 
ture of this fascia. This rarely occurs, yielding above 
at the pubic symphysis being more frequent. In the 
latter event the extravasated fluid burrows outward 
along the groins. 

Fig. 15 shows very beautifully the manner in which 
this fascia invests the penis. 




FIG. 15. 

Buck's Fascia, showing body of penis dissected up, exposing cavity 
comprised by the fascia.— {After Gurdon Buck.) 

Muscles of the Urethra. — The muscles surround- 
ing the urethra are of the greatest physiological and 
often of pathological importance. The special urethral 
muscle is the accelerator urinse or compressor ure- 



MUSCLES OF THE URETHRA. 21 

thrae. This consists of a layer of fibres, chiefly obliquely 
arranged, which surrounds the urethra from the pros- 
tale to the bulb, being relatively sparse in front but quite 
thick and numerous in the bulbo-membranous region. 
The function of this muscle is to act in conjunction with 
the longitudinal, circular and elastic fibres of the ure- 
thral walls in expelling the urine and semen. The last 
few drops of urine and semen are extruded by a contin- 
uous wave of contraction. If this vermicular wave of 
contraction be interfered with as in stricture, a portion 
of fluid is apt to be retained in the canal to dribble 
away at will as soon as the penis is allowed to assume 
the dependent position. These muscles also enter into 
the "cut off" function to be described. 

It is probable that all the perineal muscles are con- 
cerned in the urinary and generative functions. The 
muscular tissue of the prostate body, the transversus 
perinei and even the levator ani act in conjunction with 
the urethral muscles proper, in expelling fluid and in 
cutting off the flow of urine at proper and improper 
times. These various muscles compose the group de- 
scribed by Cruveilhier as one muscle — the transverso- 
urethral or voluntary cut-off muscle. A peculiar physi- 
ological circumstance is involved in the action of this 
muscle. We cannot will all the elements of this muscle 
to contract, our volitional control consisting merely in 
our ability to relax the muscles of the sphincter proper 
from their normal condition of tonicity. In the case of 
the perineal group, however, we may bring about vol- 
untary contraction and either expel fluid or assist in cut- 
ting off the flow of urine. The perineal muscles then, 
are merely auxiliary to the sphincter proper, which 
comprises the muscle of the prostate, the acceler- 
ator urinae, a few circular fibres at the vesical 
neck, and the muscular walls of the membranous 
urethra. While the bladder is not functionating, 
the sphincter represented by these several muscles 



22 



ANATOMY OF THE URETHRA 



is in a state of tonic contraction sufficient to resist the 
normal elasticity and tonicity of the detrusor urinae or 
muscular wall of the bladder. By volitional effort we may 
inhibit the action of the muscles composing the sphinc- 
ter vesicae, when, the action of the detrusor urinae com- 
ing into play, the urine is immediately expelled. Emo- 
tional excitement may interfere with our volitional con- 
trol over this group of sphincteric fibres, and also inhibit 
the detrusor urinae, with the result that urination be- 
comes temporarily impossible. This is the explanation 
of the inability of the average man to urinate in the 
presence of others. This condition is not, as is uni- 
formly claimed, one of spasm. Reflex or direct irrita- 
tation may, however, cause spasmodic contraction of the 
entire group of perineal and urethral muscles with 




Anttrie r Layjtr ef 
Ditp PrnntaJ Fitcia romtvad 
She. 
_^___ COMFUCMOR U«ETH«* 

//'^l V W l„tcrr,«l PudU Arty. 

-AH? <f tht B°.H 
Cvnjuri Gland 



FIG. 16. 

Showing deep perineal fascia (Triangular ligament), with its anterior 
layer removed. — {After Gray.) 

resulting spasmodic stricture and perhaps complete and 
prolonged retention. This condition may be produced 
by irritation of any part that is associated with these 
muscles through the medium of a common or associated 
nerve supply. Irritation is ahvays necessary to the produc- 



TRIANGULAR LIGAMENT. 



23 



Hon of spasmodic stricture-. Emotional excitement never, 
in my opinion, produces it. 

Triangular Ligament. — The deep perineal fascia 
or triangular ligament, so-called, bears a relation to the 
general deep fascia somewhat similar to that which ex- 
ists between Buck's fascia and the general superficial 
fascia. It consists of a dense membranous septum from 
the deep fascia which closes in the anterior portion of 
the pelvic outlet. As its name implies it is of a triangu- 
lar form It is firmly attached above to the sub-pubic 
ligament and pubic symphysis, and laterally to the pubic 
and ischiatic rami. Its base is directed toward the rec- 
tum and becomes blended with Buck's fascia just behind 
the transversus perinei muscle. 




FIG 17. 

Diagrammatic section of perineum showing arrangement of the trian- 
gular ligament (deep perineal fascia), a. Corp. cavernosum. b. Inferior 
layer of triang. ligt. c. Transversus perinei muscle, d. Urethra, e. Cowper's 
glands, f. Superior layer of triang. ngt. g. Internal pudic artery, h. Inter- 
na, pudic nerve, i. Descending ramus of ischium, j. Superficial fascia, 
k. Erector penis muscle. 1. Bulb. in. Accelerator urinae muscle, n. Super- 
ficial fascia, o. Superficial perineal artery, p. Superficial perineal nerve. 
q. Skin. — {After Tillaux.) 

The triangular ligament is very important in its 
relations to the surgical anatomy of the perineum and 
urethra. It consists of two layers, an anterior and a 
posterior, forming, so to speak, a space which contains 
some very important structures. It is traversed by the 
membranous urethra, which begins about an inch below 
the pubic symphysis. One-fourth of an inch above it 



H 



ANATOMY OF THE URETHRA. 



is found the dorsal vein, artery and nerves of the penis, 
which are given off in the space enclosed by the trian- 
gular ligament, from the pudic artery and nerve. Within 
this space are also to be found the arteries of the bulb, 
and Cowper's glands, one upon either side. The trian- 
gular ligament is chiefly important because of the fact 
that it is in this region that deep stricture of the urethra 
is usually located. It is the opening of the urethra as 
it enters the triangular ligament that the surgeon seeks 
to outline and enter in perineal section without a guide. 




Artery of Corput Cavsmoittm 
Lion a I Artery y> Pent* 



Artery tf Bulb, 
Internal Pudic Artery 



Vowpere Gland 



FIG. I*. 

Deep dissectian of perineum showing rectum turned aside and rela- 
tions of prostate, seminal vesicles, bulb and membranous urethra. — {After 
Gray.) 

The principal point to be remembered is the location of 
the urethra with reference to the pubic symphysis. By 
bearing this in mind the surgeon will not dissect at ran- 
dom into the pre-rectal space in a frantic effort to find 



THE MEMBRANOUS URETHRA. 



25 



the urethra, a blunder that I have seen made on several 
occasions. 

It is interesting to note that in injuries to the perin- 
eum the resulting traumatic stricture occurs in the mem- 
branous region. At this point the urethra is caught be- 
tween the sharp lower border of the sub-pubic ligament 
and the impinging body. The sub-pubic ligament being 
sharp-edged and almost as hard as bone, the urethra is 
apt to be seriously injured even from comparatively 
slight blows; indeed, it requires but moderate force to 
sever it completely. The resulting stricture is the worst 
variety with which we have to deal. 

A clear idea of the relations ot the various parts in 
the perineum is quite essential to skillful surgery in 




FIG. 19. 

Showing relations of bulb, membranous urethra and prostate to the 
deep perineal fascia or triangular ligament.— {After Gray.) 

this region — quite as essential in urethrotomy with or 
without a guide, as in operating for stone. The relative 
positions of the bulb, prostate, membranous urethra 
and rectum are well shown in Fig. 18. The relations of 



26 ANATOMY OF THE URETHRA. 

these structures are to be borne in mind in operating in 
this region, and a little time devoted to their review 
prior to undertaking an operation upon the deep ure- 
thra is never out of place. 

Fig. 19 shows very clearly the relations of the vari- 
ous parts as seen in a vertical section in the median 
line. 



CHAPTER II. 



CURVE OF THE URETHRA.— INSTRUMENTA- 
TION OF THE URETHRA. 

In order to thoroughly comprehend the essentials 
of the diagnosis and treatment of urethral stricture, it 
is necessary to have an intelligent idea of the normal 
conformation of the urethra and some of the details of 
instrumentation of the canal. One of the most impor- 
tant points is the normal curve of the urethra. The 
relations of this curve to the passage of instruments is 
a matter requiring the closest attention, and the posses- 
sion or lack of knowledge in this regard is likely to 
determine in a great measure the result of the diagnosis 
and treatment of genito-urinary disorders. The surgeon 
who is ignorant in this direction can be but a bungler in 
urethral and bladder surgery, and bungling is nowhere 
more likely to prove disastrous than in this situation. 
It may also be said that accurate knowledge and 
manipulative skill is nowhere attended with more grati- 
fying results. 

NORMAL CURVE OF THE URETHRA. 

As has already been remarked, the pendulous 
urethra has a variable curve, the direction and confor- 
mation of which may be modified by changes in the 
position of the penis. It may also be adapted to any 
form of instrument necessary for urethral or bladder 
manipulation. It is different however with the deep 
urethra. Posterior to the anterior opening in the 
triangular ligament, the urethra presents a relatively 
fixed curve, which, while it may be adapted to instru- 
ments of improper form and may even admit straight 
instruments, can only be so adapted by the use of 
some force, the infliction of considerable pain, and 

?7 



28 



NORMAL CURVE OF THE URETHRA. 



danger of subsequent inflammation, which may involve 
the bladder, prostate, seminal vesicles, or testes. Rupture 
of the urethra may be produced by such faulty instru- 
mentation. The curve of the urethra is altered by 
disease as has already been stated. Prostatic enlarge- 
ment, tumors of the vesical neck and distention or the 
bladder are the principal conditions which lengthen the 
urethral curve and make it less abrupt. 

The average normal curve as established by Bell, 
and verified by Thompson, Van Buren and others, cor- 
responds to a circle three and one-fourth inches in 




diameter, the proper length of curve for adaptation to 
the deep urethra being an arc of this circle subtended 
by a chord two and three-fourths inches in length. 

The exact measurements are shown in the accom- 
panying diagram^ Fig. 20. 

The length of curve as outlined by Thompson is too 
long for instruments as a rule. The shorter the beak 



CURVE OF INSTRUMENTS. 



2Q 



of the sound,— providing it be adapted to the normal 
curve,— the more thoroughly under control will the in- 
strument be during instrumentation. A long curve, as 
Van Buren and Keyes long ago very properly asserted, 
is apt to cause unsteadiness and wabbling as the instru- 
ment enters and traverses the deep urethra. In case of 
obstruction, a long curve is likely to do more damage, 
if force be used, — as a more powerful leverage can be 




FIG. 21. 

Showing the comparative curves of metallic sounds and catheters, 
tavored by various prominent surgeons. Benique, C B. D. Bumstead. F 
B. E. Gouley, A. B. E. Otis, F. B. E. Van Buren and Thompson, A. 

exerted by slight force,— than is the case with instruments 
of a short curve. 

There has been considerable variation in the 
curve of sounds and catheters as designed by 
different surgeons. Unfortunately also, it would appear 
that no two instrument makers use the same standard 



30 INSTRUMENTATION OF THE URETHRA. 

of construction. The French or Benique sound is per- 
haps the most faulty. This instrument was originally 
designed for use in cases in which it is desirable to allow 
a sound to remain in the bladder for some little time, 
it being supposed that the double curve made the in- 
strument more comfortable to the patient. This idea is 
most fallacious, as all possible advantages are more than 
counterbalanced by the outlandish curve and the great 
distance to which the instrument penetrates the blad- 
der. As a rule, the less the bladder is interfered with 
in passing sounds, the better. 

In treating the prostate and vesical neck, or a 
stricture at the bulbo-membranous region, it is not 
necessary to explore the entire abdomen. I have known 
surgeons who, in treating stricture, even of the pendulous 
urethra, appeared to be trying to explore the patient's 
pharynx with the beak of the sound. 

Figure 21 shows some of the varying curves 
of sounds and catheters recommended by various 
prominent surgeons. 

INSTRUMENTATION OF THE URETHRA. 

There is probably no department of surgery in which 
special skill is more pre-eminently necessary than in 
diseases of the genito-urinary organs, yet it is safe to 
say that in no department are so many abuses practiced. 
Men who would not think of prescribing for a diseased 
eye, will deliberately set about the treatment of severe 
and complicated urethral and bladder affections, which 
more urgently demand a specialist than the average 
case of ocular disease. To the average physician, the 
urethra is a canal through which an instrument ought 
to go and should be made to go, under any and all cir- 
cumstances and at all hazards. 

The results of this "stove pipe" surgery are really ap- 
palling, from the standpoint of mere mechanical results, 
to say nothing of the long train of patients with infected 



ANTISEPSIS AND ASEPSIS. 3 1 

bladders, damaged kidneys, prostatic abscesses, and false 
passages that follow in the wake of the incompetent sur- 
geon. I feel that it is no exaggeration to state, that in 
no department of surgery is special skill so necessary, and 
at the same time so ignored, as in the surgical diseases 
of the genito-urinary organs. But, it may be asked, 
"mustwe sendall of our profitable cases to thespecialist?" 
By no means, providing the treatment of the case is 
likely to prove profitable to the patient as well as to the 
physician. But if, on the other hand, the physician is 
not competent to treat this class of affections, the patient 
will, on the average, stand a better chance if left to his 
own resources, than if submitted to the tender ministra- 
tions of a surgical blunderer. 

As a preliminary to the purely mechanical features 
of urethral instrumentation, it is well to consider in 
how far we may apply modern surgical technique to 
this region. 

MODERN ANTISEPTIC AND ASEPTIC METHODS AS APPLIED 
TO URETHRAL SURGERY. 

There are many insurmountable difficulties in the 
way of absolutely aseptic and antiseptic methods in the 
treatment of genito-urinary diseases. The various 
portions of the genito-urinary tract are comparatively 
inaccessible, are colonized by germs of various kinds, 
and are bathed from time to time — or constantly, as the 
case may be — with a fluid, which, harmless per se — save 
by its irritating chemical properties — may yet be the 
carrier, or nidus for the development of noxious germs 
and their toxic products. 

In short, drainage of these parts is very defective. 
To be sure, the germs that find their habitat in the 
urethra are not always noxious, but I hold the opinion 
that they may all — by evolution in a favorable environ- 
ment — become pathogenic. A sound cannotbe passed in- 
to the bladder, in all probability, without carrying in a 



32 INSTRUMENTATION OF THE URETHRA. 

quantity of germs and germ products from the urethra. 
If, however, the bladder be normal, no injurious results 
will occur. If there be only a slight amount of residual 
urine in the bladder, decomposition may be set up and 
a cystitis will result. No matter how carefully we may 
attend to aseptic and antiseptic details in passing instru- 
ments for evacuating this residual urine, cystitis arises 
sooner or later. Indeed, it will arise even where no 
instrumentation whatever is practiced. Germs are ever 
present in the urinary tract, and their result depends 
entirely upon the local circumstances of environment. 
Germs of known pathogenic properties, and materials 
which may be elaborated by previously harmless germs 
into toxic compounds, are of course most likely to cause 
infection when conveyed into the urethra or bladder by 
unclean instruments. 

As a broad general proposition, it may be accepted 
that, while we cannot as a rule prevent germs entering 
the genito-urinary tract, we may, by strict asepsis, anti- 
sepsis and drainage, obviate the dangers of operations 
to a very marked degree. We can usually avoid the 
direct introduction of pathogenic germs and their 
products, and we can certainly avoid the introduction of 
morbific material upon which the normal germs may 
feed, wax fat and become noxious. We may also, to a 
great extent, remove or neutralize the septic properties 
of material which may form in the genito-urinary organs. 

A point well worthy of attention in this connection, 
is the fact that the delicate structures of these parts do 
not tolerate very strong antiseptics. 

Another circumstance having a decidedly practical 
bearing upon urethral surgery is the difficulty of obtain- 
ing rest. The penis is subjected to varying conditions 
of blood supply, incidental to various irritations of a 
sexual or ordinary character. The bladder and urethra 
are also frequently disturbed by the accumulation and 
discharge of the urine. 



CARE OF INSTRUMENTS. 33 

The best means of preventing infection of the 
genito-urinary tract by instrumental manipulations are 
embraced in the simple term, cleanliness. A perfectly 
clean instrument is as aseptic as may be, but one which 
is in the slightest degree contaminated is fraught with 
great danger to the patient. The unfortunates who 
have been slain, or hopelessly crippled, by a dirty cathe- 
ter or sound, in the hands of a dirtier doctor, might, if 
the truth were known, rival in numbers those troops of 
shades with uncured gleets, whom Ricord said he met 
in Purgatory. 

The most effective means of aseptizing instrument's 
is by boiling, or the use of the steam sterilizer. Before 
all cutting operations upon the urethra this plan should 
always be followed. In ordinary everyday office routine, 
however, this is not so practicable, nor is it, perhaps, 
absolutely essential. The surgeon should provide 
himself with an instrument tray, which will hold the 
necessary syringes, sounds, etc. In this tray the instru- 
ments should be kept in a bath of 5 per cent carbolic- 
acid solution. Each instrument should be immersed in 
this solution before being used, and after use should be 
carefully wiped on a clean cloth and returned to the 
bath. If the instruments are well polished and plated, 
they will not rust in the bath if immersed for a short 
time. The appearance of rust in the water, or on the 
instruments, means a defect in the plating. 

Too much care cannot be given to the surface of 
sounds and other metallic instruments; — the slightest 
defect constitutes a nidus in which morbific material 
may lodge. Irregularities of surface are also very irri- 
tating to the delicate mucous membrane of the urethra. 
A perfectly smooth sound will often pass readily where 
a slightly defective instrument will excite the most in- 
tense urethral spasm. The same remarks are pertinent 
as applied to soft bougies and catheters. These 
latter lose their gloss quite readily, the more especially 



34 INSTRUMENTATION OF THE URETHRA 

as antiseptic solutions and hot water are very destructive 
to them. The pure rubber variety, however, will stand hot 
water and carbolic solution much better than the woven 
and gum catheters Immersion in a i to 1000 bichloride 
solution is quite effective and not so detrimental to soft 
instruments as solutions of carbolic acid. Before all 
important operations on the urethra the canal should 
be Mushed out with a solution of bichloride, i to 5000, or 
a saturated solution of boric acid. 

Lubricants for Instruments : Time was, when the 
armamentarium chincrgictim of the g.enito-urinary sur- 
geon was not considered complete without a bottle of 
rancid smelling olive oil for lubricating purposes. If the 
surgeon could procure a bottle of pomade in its sere and 
yellow leaf, then indeed was he happy. This condition 
of affairs has unfortunately not entirely disappeared. 
Should the novice suppose that this is an overdrawn 
picture, let him inspect the tables of the first half-dozen 
general practitioners with whom he comes in contact and 
see what he will find. If he does not meet with my ex- 
perience, and find a few of them using the soap from 
their office sinks, as a lubricant for their sounds and spec- 
ula, he may be satisfied that the world does indeed 
move and is taking the dirty doctors along with it. The 
modern petroleum preparations are to a certain extent 
antiseptic, and as they are quite stable, they are much 
to be preferred to ordinary fats and oils for lubricat- 
ing urethral instruments. Carbolized vaseline in 2 per 
cent strength, or sublimated vaseline 1 to 1000 are very 
serviceable. It is not unwise to add the muriate of 
cocaine five grains to the ounce. One of the latest and 
best of the petroleum preparations is the liquid albo- 
lene. I am using this to the exclusion of everything 
else. • 

In cases in which the sound is to be followed by 
astringent or antiseptic applications, some form of lubri- 
cant should be used which will not coat the mucous 



SELECTION OF INSTRUMENTS. 35 

membrane with a substance impenetrable to medi- 
caments. Glycerine and egg albumen are unobjection- 
able from this standpoint, although neither of these 
materials is as efficacious as a lubricant as the oils and 
fats. Glycerine is quite irritating to some urethrae. 

The following formula constitutes an excellent lu- 
bricant. 

Hydg. Bichlor. gr. ss. 

Cocaine Mur. gr. v. 

Liq. Albolene 3 j. 
M. 

By heating the Albolene before adding the 
bichloride, a more satisfactory mixture is ob- 
tained. 

Instruments should be warmed, as a rule, before 
their introduction into the urethra. Not only is their 
passage thereby facilitated, but urethral chill is much 
less likely to occur. There is the greatest imaginable 
difference in the readiness with which warm and cold 
sounds enter the urethra, as may be demonstrated by 
anyone who cares to make the test — and there is no test 
equal to the passage of an instrument upon oneself' 
Urethral chill is often greatly a matter of nervous shock, 
hence the wisdom of warming urethral instruments as a 
prophylactic of rigors. Obviously, the reflex impression 
is likely to be most profound from a cold instrument. 

SELECTION OF INSTRUMENTS. 

Size of instrument : The most useful rule which can 
be formulated for our guidance in urethral surgery is, 
never to introduce an instrument which will not pass 
without the exertion of any great degree of force. The 
general and trite maxim is, never to pass an instrument 
which will not enter by its own weight. This is 
a most ridiculous proposition in some respects. It will 
apply to the normal urethra and to large sized sounds, 
but not to canals of small calibre due to pathological con- 



36 INSTRUMENTATION OF THE URETHRA, 

ditions. The very men who formulate this rule in text- 
books, are violating it daily in practice; if they do not 
do so, they certainly must fail to pass an instrument 
quite frequently. I do not believe that any arbitrary 
rule can be formulated. In a general way it maybe 
said, that an instrument which requires for its passage 
any more force than is necessary to adapt it to the canal 
and keep it in the proper line, is too large for intro- 
duction. Wedging an instrument through an obstruct- 
ion is bad practice. Only long experience can teach 
the surgeon when, where, and in what degree he may 
use force in passing instruments upon the urethra. No- 
where is the tortus erndihis, born of clinical experience, 
as essential as in genito-urinary surgery. In a general 
way the proposition is a safe one, that instruments are 
to be coaxed, not driven through the urethra. The sur- 
geon who does the most coaxing and the least driving, 
is the true artist in genito-urinary work. 

Small instruments of metal should never be intro- 
duced into the urethra where possible to avoid them. 
In dilating stricture, soft instruments should be used, up 
to a calibre of eighteen to twenty Fr., after which the 
steel sounds should be substituted. I am very much 
puzzled to understand why it is, that instrument makers 
will persist in getting up sets of sounds for professional 
tyros, scaling down to the size of a knitting needle. To 
my mind, the man who displays such a set of instruments 
makes out an excellent prima jocie case of daily and 
frequent malpractice against himself. As to the manu- 
facturer who may design these abominable "sets" for 
the unwary recent graduate, he ought to be prosecuted 
for aiding and abetting homicide. 

SCALING OF SOUNDS AND CATHETERS. 

As is well known, the numbering of sounds and 
catheters has been greatly a matter of caprice with 
various instrument makers. It makes the average man 



SCALING OF INSTRUMENTS. 37 

very weary to even attempt to understand the precise 
significance of the numbers upon instruments. Instru- 
ments supposed to be numbered upon the English or 
American scales are found to vary in a marked degree, 
the same numbers on the same scales rarely correspond- 
ing in instruments of different makes. The length of 
sounds varies quite as much as the diameter, a differ- 
ence of two or three inches in length of sounds of 
different makers being nothing unusual. The only 
approach at uniformity of measurement of diameter, 
is the French scale. This, if accurately followed, 
reduces the measurement of instruments to mathe- 
matical exactness. The numbers of the French scale 
indicate at once the circumference of the sound 
or catheter. Beginning at No. i, each increase in 
number indicates an increase of one millimetre in circum- 
ference. For practical purposes this fine gradation of 
sizes is not necessary, every second number being all- 
sufficient for everyday use. A set of sounds comprising 
every other number, from thirteen to thirty-five Fr., in- 
clusive, forms a practical outfit. This is especially true 
because of that fact that the modern conical sounds vary 
in size from the beginning of the curve to the tip. A 
urethra which will take the shaft of one instrument will 
certainly admit the point of the next larger size. A very 
useful device for determining the size of instruments are 
the scale plates shown in Figs. 22 and 23. These have 
the several scales marked upon them. 

The conical point is a great improvement over 
the old-fashioned, relatively blunt instrument, especi- 
ally as regards its facility of introduction. A little 
more care, however, is necessary in its use, as it acts 
decidedly upon the wedge principle, and the surgeon is 
likely to be tempted to introduce a larger instrument 
than is wise. 

FORM OF SOUNDS AND METALLIC INSTRUMENTS. 

A few general remarks regarding the most desirable 



38 



INSTRUMENTATION OF THE URETHRA. 



form of sounds may be of service. In a general way it 
may be stated that a properly made sound should be as 
short as is compatible with the length of the urethra. 
There is a tendency on the part of instrument makers 




\ 





i 


i 




2 




2 




3 




3 


I * 




5 




4 




6 




s 

6 
7 

8 


7 




8 




9 




1 io 









1 U * 


T> 


9 


13 




14 


^ 


10 




IS 
16 


ll 


1 17 




12 

13 


o 


18 


z 

W 


1 19 

I 20 

21 

22 


14 
15 
16 
17 


o 


1 23 


> 

r 


1 a * 


1 2S 


1 2fi 


i'i 


18 


1 27 
1 28 




19 




1 29 
1 30 




20 
21 
21 
23 
_24 
25 
26 




31 

32 




33 1 




3* 
35 

f"37_ 

p8 
\~39 
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r O 



O.REYNnERS&CO. 



FIG. 23, 



FIG. 22 



to manufacture the most ungainly instruments that can 
possibly be devised. Every fraction of an inch in the 
length of a sound, over and above what is really neces- 



METHOD OF INTRODUCTION. 39 

sary to enter the bladder, makes the instrument pro- 
portionately more difficult to manage. As already stated, 
the farther the point of the sound is from the hand, the 
less the control of the operator over the instrument, 
and the greater the danger of inflicting injury by care- 
less manipulations. It does not seem to dawn upon 
some surgeons, that in dilating or exploring for stricture, 
it is not absolutely essential to punch the point of the 
sound violently against the fundus of the bladder. It isby 
no means necessary to superadd traumatic cystitis to ure- 
thral stricture. A comparison of different makes of 
instruments shows the greatest imaginable variation in 
length. I have in mind at the present moment, a set of 
sounds furnished by an instrument house of this city to 
one of our hospitals, that are monstrosities of form. 
The man does not live whose urethra can take the full 
length of one of these sounds without the point pressing 
forcibly against his bladder — unless the latter be dis- 
tended. Every time a sound of this kind is introduced 

in the'orthodox manner — with 
the handle well down be- 
tween the thighs — the bladder 
walls are bruised by the point 

^3g ^ y of the instrument. 

___ ^ properly made metallic 

fig. 24. instruments, the point is at a 

right angle with the shaft, as shown in the accom- 
panying illustration. 

METHOD OF INTRODUCTION OF INSTRUMENTS. 

Nothing could be more difficult than to convey an 
understanding of the proper method of instrumentation 
of the urethra by mere verbal description. Only care- 
ful clinical instruction and considerable personal ex- 
perience, will impart a practical working idea of the 
subject. There are some points of a general character, 
however, upon which it is always profitable to elaborate 




40 INSTRUMENTATION OF THE URETHRA. 

in a work of this kind. These points may be covered 
by a description of the introduction of an ordinary 
sound or catheter. 

The late Professor S. D. Gross, was wont to say, 
regarding the magnitude of operations upon the ure- 
thra: 'The introduction of the sound is one of the 
nicest, and most delicate processes of surgery. It re- 
quires skill of the highest order, as well as the most in- 
timate knowledge of the anatomy of the urinary organs. 
If I were called upon to state what I considered as the 
most important operation that a practitioner is called 
upon to perform, I should unhesitatingly say, the intro- 
duction of a sound." This assertion from the Nestor of 
American surgery is more than the most arrogant of 
genito-urinary specialists could ask for; it certainly is 
enough to warn the ignorant bungler of the dangers to 
which he subjects his hapless patients with genito- 
urinary affections, every time he inserts an instrument 
into the urethra. 

I am often asked by medical students, whether I 
cannot suggest some method of training by which they 
may become proficient in urethral instrumentation, I 
invariably advise them to practice the necessary manipu- 
lations upon themselves. Once let a man become in- 
timately acquainted with the sensation imparted by a 
sound or catheter and he acquires a tactics eruditus which 
yearsof observation would fail to impart to him. My per- 
sonal opinion is that no man is competent to pass an instru- 
ment upon a patient until he has practiced the maneuver 
ttpon himself a few times. 

To a certain class of surgeons, urethral manipula- 
tions afford a grand opportunity for theatrical display. 
I have in my mind's eye at the present writing a cele- 
brated eastern surgeon, whose antics, when standing 
before his class, sound in hand, are a symphony of 
flourishes. Another well-known western surgeon, whom 
I have seen operate on many occasions, introduces a 



OPERATION OF INTRODUCTION. 41 

sound with so rapid and triumphant a sweep and such 
a self-satisfied "see-me-do-it" expression that my fingers 
fairly itch to thrust a 40 French into his anatomy as an ot> 
ject lesson in urethral surgery. It would be interesting 
to know how many ruptured urethrae, urinary extrava- 
sations, fatal urethral chills and false passages are 
credited to this man in the book of errors. To the 
student who has been taught by conservative, modest 
and pains-taking surgeons, this digression is a work of 
supererogation, but to him who has been dazzled by the 
aesthetic flourishes of the surgical fop or the boister- 
ous self-sufficiency of the surgical ruffian, the foregoing 
remarks may be serviceable. All that glitters is indeed 
not gold in the surgery of the genito-urinary apparatus. 
In the description of the proper method of passing 
urethral instruments, I shall waste no time in resurrect- 
ing such relics of the past as the tour de maitre. This 
maneuver, and those which are a compromise with it, 
cannot too soon be consigned to the oblivion of the 
dead lumber room of surgical* fads and fancies. It is 
unworthy of discussion, and to present it would be an 
invocation of ghostly witnesses of its barbarity. 

OPERATION. 

The patient should be placed upon his 
back, preferably in the semi-recumbent posture, with 
the thighs flexed upon the abdomen and the legs upon 
the thighs. The feet should rest on a support at a 
lower level than the body. The small platform of the 
ordinary gynaecological chair is very convenient as a 
foot-rest. After the patient has become used to the 
passage of instruments they may be introduced in a 
standing position if desired. In some patients I have 
found that a sound or catheter may be introduced with 
more facility with the patient in the erect position. 
Until the patient has become inured to instruments, how- 
ever — and invariably when there is the slightest ten- 
dency to syncope during instrumentation — the recum- 



4^ 



INSTRUMENTATION OF THE URETHRA. 



bent position is imperatively necessary. It is a de- 
cidedly unpleasant experience to have a patient unex- 
pectedly fall to the floor in a dead faint, during the 
passage of a sound or catheter. 

The patient being in proper position, the instrument 
should be rendered aseptic, warmed and well lubri- 
cated with some antiseptic lubricant mixture. 

The operator had better become accustomed to the 
use of either hand in introducing instruments. As in 
all special regional surgery, ambidexterity is here of 
great service. If the instrument is to be passed with the 
right hand the surgeon should stand on the left of the 

patient and vice versa. 
The instrument should 
be held in the hand 
pen fashion, and not 
grasped as if it were a 
club. The penis is 
held lightly between 
the fingers and thumb 
of the opposite hand 
and the point of the 
instrument engaged in 
the meatus. (Fig. 25.) 
The shaft of the 
instrument should be 
parallel with Poupart's 
ligament and almost in contact with the body of the 
patient. The instrument being now in proper position 
for introduction, the penis is slowly and gently drawn 
up over the instrument with the free hand until about 
four inches of the curve and shaft have been intro- 
duced. The handle is now gradually raised, the point 
being at the same time dipped well down toward the 
perineum. When the point has arrived approximately 
at the opening in the triangular ligament, the handle 
should be swept toward the median line of the patient's 




fig, 25. (Keyes.) 



OPERATION OF INTRODUCTION. 



45 



that it exists. I have heard a surgeon say that he 
thought a certain stricture was "spasmodic," upon which 
he thrust a sound into the bladder as rapidly as pos- 
sible, "to take the muscles by surprise," he said; but to 
my notion forthepurpose of display. Thisgentlemanhad 
no authority even for the assumption that his patient had a 
stricture, and as for determining its character without 
exploration, that was obviously impossible. Had 
the patient's urethra been organically obstructed 
I fail to see how it could possibly have escaped 
serious injury. This was, however, a fair sample 
of the work of the "stove-pipe" surgeon, whose 
apprenticeship should be in a plumber's shop rather 
than in a physician's office; and there are many of 




I'IG. 3^>- 

Showing position ol instrument in rinal stage oi its introduction. — {Af- 
ter Voillemicr.) 

his ilk who fill high places, with profit to themselves 
even if with disaster to their patients. 

A very little deflection from the proper line as the 
sound or catheter enters the perineal portion of the 
urethra is sufficient to cause great trouble in introduc- 
tion. The temptation, of course, is to use force in the 
further passage of the instrument. 

It must be remembered, however, that the mtroduc- 



4 6 



INSTRUMENTATION OF THE URETHRA. 



tion or an instrument should be a process of coaxing — 
not driving. The more the operator tries to force his 
way through, the more resentful the sensitive urethra 
becomes. Let slowness and gentleness be the watch- 
word, and the surgeon is not likely to do damage in his 
urethral work. 

Very often the point of the sound is arrested by 
spasm at the musculo-membranous region. A little 
steady and gentle pressure will usually overcome this 
obstruction. Very often diversion of the patient's mind 




FIG, 3L. 

Showing correct and faulty positions of point of an instrument at the 

bulb. — {After Culver &= Hay den.) 

is all that is necessary, as much of the obstruction is 
caused by voluntary contraction of the auxiliary cut- 
off muscles. In some instances the spasm will be 
relaxed by a voluntary effort to micturate. This brings 
the physiological inhibition of the cut-off muscle to the 
assistance of the surgeon. A hypodermic of morphia 
half an hour before the exploration is often of value. 
A few drops of a two to four per cent, solution of 
cocaine instilled into the urethra five minutes before 
-ije stance are usually effective, but must be employed 



OPERATION OF INTRODUCTION. 47 

with extreme caution. Full anaesthesia may be neces- 
sary. 

Dipping the point ol tne instrument well uown into 
the perineum before sweeping the handle to the median 
line, is a most valuable procedure and renders the 
introduction of an instrument much easier. 



CHAPTER III. 



STRICTURE OF THE MALE URETHRA. 

Definition and Varieties, 
spasmodic, congestive and inflammatory stricture. 

Stricture of the Male Urethra is by far the most 
important of all the surgical diseases of the genito-urin- 
ary apparatus. It is of importance not only because of 
its extreme frequency, — the special condition .which most 
often gives rise to it affecting sooner or later a large pro- 
portion of male humanity, — but because of its important 
relations to secondary pathological conditions of organs 
more vital than the structure primarily affected. 

Stricture of the urethra may be defined as an ab- 
normal diminution of the lumen of the canal at one or 
more points or throughout its entire course, due to any 
cause whatsoever, whether temporary or permanent. 
Thus it may arise from any of the following conditions: 

i. Pressure from without, due to (a) neoplastic for- 
mations; (b) extravasations of blood or urine from injury; 
(c) purulent collections and infiltrations; (d) fracture of 
the pelvic bones. 

2. Spasm of the muscles in and about the uiethra, due 
to: (a) direct irritation by lesions of the canal; (b) 
direct or reflex irritation from foreign bodies in the 
canal; (c) reflex irritation from more or less remote 
pathological conditions; (d) the introduction of instru- 
ments; (e) emotional excitement; (f) malaria (?); (g) 
highly acid and concentrated urine and occasionally 
oxaluria and gravel. 

3. Congestive or inflammatory eiigorgcment of the 
urethra, due to: (a) acute urethritis; (b) traumatism of 
the urethra; (c) inflammation in and about organic ob- 
structions. 

48 



CONDITIONS PRODUCING STRICTURE. 49 

4. Thickening of the urethral walls', due to: (a) con- 
gestive and granular patches in the mucous membrane, 
i. e. superficial infiltration from chronic inflammation; 
(b) plastic infiltration and formation of connective tis- 
sue in the meshes of the corpus spongiosum, from 
severe and long continued inflammation; (c) cicatricial 
deposit in the corpus spongiosum and urethral walls in- 
cidental to traumatism; (d) cicatricial deposit incidental 
to the action of various caustics and powerful irritants; 
(e) cicatricial deposit incidental to ulceration or 
sloughing from impaction of foreign bodies. 

5. Deficient elasticity of the urethral walls and corpus 
spongiosum', (a) from congenital sparsity of elastic and 
muscular fibre and a preponderance of fibro-connective 
tissue; (b) from inflammation. 

6. Congenital narrowing of the urethra, or slight 
atresia from defective fcetal development. 

7. Polypi of the urethral mucous membrane. 
From a clinical standpoint, strictures may be divided 

as regards their origin into: "(i) congenital; (2) ac- 
quired, (a) traumatic; (b) chemical; (c) acute inflam- 
matory or congestive; (d) chronic inflammatory; (e) 
neurotic. 

As regards the essential condition producing the 
obstruction, they may be divided into: (1) spasmodic; 
(2) congestive or inflammatory (circumscribed or gen- 
eral) ; (3) organic or fibrous (permanent), i.e. neoplastic. 

Those varieties of stricture, the nomenclature of 
which depends upon real or supposed differences in the 
condition producing the obstruction, are not always to 
be differentiated clinically because of the fact that the 
several conditions may co-exist and be blended in vary- 
ing proportions in any given case of the disease. Thus 
inflammatory or congestive narrowing of the urethra, 
although sufficient/^ se to produce obstruction in some 
cases, is nearly always complicated by spasmodic nar- 
rowing of the canal. Simple spasmodic stricture is rela- 



50 STRICTURE OF THE URETHRA. 

lively rare, occurring only as a result of reflex irrita- 
tion of a remote character, mental impressions, or in- 
strumentation where the urethra is very sensitive. On 
the other hand, spasmodic stricture dependent upon 
acute or chronic organic changes in the urethral mucous 
membrane is very frequent. Again, there are few cases 
indeed, of organic stricture, that are not complicated at 
one time or another by inflammation, congestion or 
muscular spasm; in fact, all of these elements — which 
I will style plus conditions — and particularly spasm, 
are apt to require attention at various times during the 
treatment of organic stricture. 

SPASMODIC, CONGESTIVE AND INFLAMMA- 
TORY STRICTURE. 

SPASMODIC STRICTURE. 

Spasmodic Stricture — or, as it may justly be called, 
pseudo-stricture — may be defined as a diminution 
of the calibre of the urethra, due to spasmodic 
contraction of the muscular fibres in and about the 
walls of the canal. Its existence was for a long time 
denied. It would appear that every day experienceshould 
have taught the practical surgeon at a very early period, 
that such a condition as spasmodic urethral stricture 
was possible. It seems, however, that such was not the 
case for some time. The varying calibre of the urethra 
during the progress of a course of treatment for stric- 
ture — or during the natural course of that disease un- 
modified by treatment — is very strikingly suggestive of 
the element of spasm, for it will often be found that a 
stricture which will at one sitting admit a sound of fair 
size, will at another time only permit the passage of a 
very small instrument, or perhaps none at all. Complete 
retention may occur at any time as a result of such ex- 
citing causes as acid urine, intemperance, sexual indul- 
gence, and so on. To be sure, spasmodic contraction is 
associated very often with congestion and inflammation, 



SPASMODIC STRICTURE. 5 1 

but in most instances spasm is the preponderating con- 
dition in the case. Again, an instrument may be ob- 
structed during its passage into the urethra until after 
gentle pressure is exerted, when it will pass the point of 
contraction quite readily. The grasping of the instru- 
ment by the urethral walls as it is withdrawn, proves 
conclusively the existence of spasmodic contraction in 
and about the canal. 

Notwithstanding the facility of demonstration of 
spasmodic stricture, the profession did not accept the 
existence of this condition until Hancock and Kolliker 
demonstrated the existence of muscular fibres in the 
urethral walls. The researches of these investigators, 
although valuable, unfortunately led to the erroneous 
inference that contraction of these fibres was the most 
important element of spasmodic stricture. A compari- 
son of the mechanical effects produced by spasmodic 
stricture, with the power of the muscular fibres which 
were supposed by them to be chiefly concerned in the 
production of the spasm, will* readily demonstrate the 
fallacy of this belief. The planes of muscular tissue are 
chiefly longitudinal and so sparse, that no matter how 
firmly they might contract, they would be incapable of 
seriously obstructing the passage of instruments, or pro- 
ducing retention of urine. We must, therefore, look 
further for the seat of the spasm in pronounced cases, 
and seek for those structures the function of which is to 
normally obstruct the canal and prevent the escape of 
urine. A group of such structures is foitnd in the cut-off 
muscle of Cruveillier, audit is at a point in the urethra cor- 
responding to this muscle, or group op muscles, that the 
principal spasm occurs. The last few drops of urine and 
semen are extruded under normal conditions by the ac- 
celerator urinae and compressor urethrae muscles; simul- 
taneously with this expulsion of fluid the cut-off muscle 
closes the deep urethra and the neck of the bladder. 
Spasmodic stricture is merely an intensification of this 



52 STRICTURE OF THE URETHRA, 

physiological function, in which, from various sources of 
irritation, the muscle is spasmodically contracted and the 
volitional power of the patient over the act of urination is 
for the time being held in abeyance. The accelerator urinae 
and compressor urethrae muscles play but a minor part 
in the production of such a spasm, the chief factor be- 
ing the contraction of the voluntary cut-off muscle. A 
certain amount of spasm however, due to contraction 
of the circular fibres of the urethra, may occur at any 
portion of the canal, and probably constitutes a certain 
proportion of the obstruction experienced in the intro- 
duction of instruments in cases of stricture of large 
calibre located in the pendulous urethra. It is this 



B 




FIG. 32. 

Fig. 32, showing the manner in which the urethra resents the passage of the bougie a boule. 
A, bulb, caught at point of narrowing, B, urethral walls opposing passage ofbulb. 

spasm which facilitates the exploration of the urethra 
by means of bulbous instruments, inasmuch as it is 
through it that the sensitive urethra resents at certain 
diseased points, the introduction and withdrawal of the 
bulb of the instrument and thus gives evidence of ob- 
struction. 

The site of spasmodic stricture varies. There are most 
always two points of spasmodic contraction: (a) At 
the point of irritation, and (b) in the musculo-membra- 
nous urethra. 



SPASMODIC STRICTURE. 53 

1. When a foreign body is introduced into the 
canal, the urethra resents the liberty at any point of irri- 
tation, and there occurs simultaneously with the slight 
contraction at the point irritated, a reflex spasm of the 
cut-off muscle. The same is true in cases of organic 
stricture in the penile portion of the urethra or at the 
meatus. The introduction of an instrument produces 
stretching and irritation of the lesion in the anterior 
portion of the canal and excites reflexly, spasm of the 
deep urethra, so that we find in quite a large proportion 
of cases of stricture, at least two points of obstruction, 
one in the diseased portion of the canal against which 
the instrument impinges, and another when the instru- 
ment strikes the deep urethra. The same spasmodic 
contraction results when the anterior obstruction is a 
congenital stricture or point of normal contraction. 
This is an important practical point, for it has been estab- 
lished that, simultaneously with the removal of the anterior 
point of obstruction and irritation, the supposed deep 
organic stricture disappears. 

2. The entire canal may be spasmodically con- 
tracted and resent the introduction and withdrawal of 
instruments. 

3. The musculo-membranous region may alone be 
involved. This happens in cases in which an organic 
lesion exists in the deep urethra and those in which 
spasm is due to reflex causes. 

CAUSES OF SPASMODIC STRICTURE. 

The causes of spasmodic stricture, may be classi- 
fied as: 

1. Predisposing Causes, (a) general hyperesthesia; 
(b) local hyperesthesia. Both of these causes are 
modified by a nervous temperament, debilitated and cach- 
ectic states of the system, the rheumatic and gouty dia- 
theses, intemperance, high-living, faulty sexual hygiene, 
etc. (c) Acute or chronic disease of the urinary organs. 



54 STRICTURE OF THE URETHRA, 

This is the most frequent predisposing cause, and it is 
rarely indeed that a case of spasmodic stricture is met 
with, in which a more or less damaged state of the canal 
does not exist. So uniformly is it present, that it is 
always to be suspected until organic disease has been 
excluded by exploration. Congested and fungating 
patches, erosions of the mucous membrane, acute and 
chronic urethritis, and stricture of whatever degree, 
constantly predispose to spasmodic contraction, both at 
the point of irritation and at the cut-off muscle; such 
predisposing causes are almost always effective in its 
production during the passage of an instrument. A 
congenital narrowing of the meatus or other parts of 
the canal, may give rise to reflex spasm of the deep ure- 
thral muscles in any case in which an instrument is 
passed, of a sufficient size to produce stretching of the 
sensitive tissues at the point of contraction. As already 
noted, when instruments are introduced under the patho- 
logical conditions alluded to, there is a spasm at the site 
of the lesion and another deep down in the canal. 

2. Exciting Causes, i, Passage of instruments; 2, 
sexual excitement or excess; 3, injury to the canal — ■ 
chemical or traumatic; 4, a debauch; 5, cold-taking; 6, 
foreign bodies; 7, drugs, such as cantharides and tur- 
pentine; 8, reflex irritation; 9, malaria (?); 10, mental 
emotions. 

A survey of the various exciting causes of spas- 
modic stricture, is sufficient to indicate the fact that in 
nearly all instances the element of spasm is associated 
with congestion and inflammation, — conditions which 
such special causes are most apt to excite. Spasm 
due to drugs is usually associated with considerable 
inflammation and attended by frequent and painful 
micturition (strangury), perhaps associated with ure- 
thral hemorrhage. The most frequent exciting causes are 
intemperance y exposure to cold and wet, and sexual excess. 
Highly acid urine in gouty patients is said to act as an 



SPASMODIC STRICTURE. 55 

exciting cause per se in some cases, but it is in the high- 
est degree doubtful if such a condition of the urine could 
bring about obstructive spasm in the perfectly healthy 
canal. It is, however, an important element in spasm 
produced by excesses of various kinds and cold-taking. 
Instrumentation of a sensitive canal, especially if or- 
ganic disease exists, is likely to develop spasmodic stric- 
ture which may last for some days or weeks. 

Cases of intermittent spasm due to malaria and 
curable by quinine are recorded, but it is questionable 
whether malaria alone can act directly as an exciting 
cause; that it may predispose to spasm is admitted. 

In passing instruments into the virgin urethra, in 
delicate and nervous patients, — whether organic disease 
of the canal exists or not, — the instrument is apt to meet 
with an obstruction in the deep urethra. This will gen- 
erally pass off under gentle and continuous pressure 
with the beak of the instrument. As the instrument is 
withdrawn, a sense of biting or grasping upon it is ex- 
perienced by the hand of the operator, and the patient 
may himself feel a sensation of traction in the urethra. 

It is a matter of common observation that some 
individuals are unable to urinate in the presence of 
others. This has been already alluded to as a form of 
spasmodic stricture from mental emotion, but it is in all 
probability due, not to spasm, per se, but to inhibition of 
the volitional power over the cut-off muscle, and of the 
normal involuntary contraction of the detrusor urinae 
muscle. 

Reflex spasm of the cut-off muscle is most apt to 
arise from irritation of structures bearing a more or less 
direct relation to the genito-urinary tract through com- 
munity of nervous supply; thus diseases of the bladder, 
kidneys, rectum and anus, are very apt to produce it. It 
is by no means an uncommon experience after forcible 
stretching of the sphincter ani in operations for hem- 
orrhoids, fistula in ano, and rectal stricture, for reten- 



56 STRICTURE OF THE URETHRA. 

tion of urine to occur as a consequence of reflex spas- 
modic stricture. Inflammation in and about the perin- 
eum may produce urinary obstruction through the me- 
dium of spasm, independently of pressure. 

The practitioner should anticipate the probable oc- 
currence of deep spasmodic stricture sooner or later, as 
an element in any vesico-urethral disease, whether acute 
or chronic. It must be distinctly understood that the 
point from which irritation is reflected, may be above 
or below the site of the spasmodic contraction, i. e., the 
perineo-urethral muscles. 

During the course of a gonorrhoea the urinary flow 
may be greatly lessened, yet sufficient for all practical 
physiological needs, when suddenly, without the least 
warning, retention occurs. And this without the slight- 
est involvement of the deep urethra or bladder. Ordinarily 
such retention means a deep extension of inflammation, 
but retention from this cause is not so sudden and is 
preceded by symptoms of prostatic or vesical irritation. 
In chronic prostatic irritation and in chronic cystitis, with 
or without calculus, sudden retention may occur at any 
time. In such cases it is congestion that constitutes the 
primal condition of obstruction, but it is the reaction of 
the muscular structures under irritation that brings 
about the sudden and final occlusion of the urinary way> 
with resulting complete retention. 

As Le Dentu expresses it: "Spasm plays the prin- 
cipal role and congestion the preparatory."* 

In hypertrophy of the prostate, the least disturb- 
ance of the usual regimen or the slightest venereal 
or dietetic excess or exposure, causes congestion of the 
deeper parts of the urethra. This may, and often does, 
excite reflex reaction of the surrounding muscles with 
consequent sudden retention. 

Some very interesting examples have been cited, 

*Le Dentu. Des spasmcs reflexes de l'urethre. Ann. des mal. des org. genito-ur. k 
April, 1892. 



SPASMODIC STRICTURE. 57 

where irritation of neighboring parts has produced 
spasmodic retention. Thus Le Dentu cites a case of 
testicular neuralgia, the exacerbations of which were 
accompanied by spasmodic retention.* The same 
author calls attention to the providential spasmodic re- 
tention that often prevents urinary extravasation in 
wounds of the urethra and perineum. 

Uterine affections in women have been known to 
give rise to spasmodic retention, and it is probable that 
post partum retention often has a strong spasmodic ele- 
ment. 

It has been held that injuries of parts very remote 
from the urinary apparatus may produce spasmodic re- 
tention. Thus a fall upon the knees, fractures of the 
ribs, surgical operations, (such as laparotomy) , and many 
other accidents of a traumatic character, are sometimes 
associated with retention. That this retention is due to 
spasm I do not believe. Inhibition of the detrusor 
urinae or of volitional power over the cut-off muscle 
due to shock, commotio-cerebri ov-commotio-spiualis, seems 
to me a much more logical explanation. There may 
indeed be an apparent retention due to reflex inhibition 
of renal secretion, especially after abdominal operations. 
In some cases, obtunding of the sensory supply of the 
bladder from shock or concussion may have much to 
do with the temporary retention. In some of the slighter 
cases, exaltation of emotional sensibility maybe a causal 
factor in the retention. A patient who has been operated 
upon or seriously injured is compelled to use a duck or 
bedpan — often with an attendant close at hand — the 
result is a temporary inhibition of the power to relax the 
cut-off muscle and consequent retention. I recently saw 
an excellent example of this. A patient upon whom 
I had operated for hydrocele by the injection of carbolic 
acid, developed retention which lasted for twenty-four 
hours. He made frequent attempts to urinate while 

*Op. cit. 



58 STRICTURE OF THE URETHRA. 

in bed, but without avail. I called upon him for the 
purpose of catheterizing him, but before passing the 
instrument had him rise from bed and try to pass 
water in a urinal. Being left to himself for a few 
minutes he immediately, and with very little effort, 
emptied his bladder. The same peculiar effect is often 
observed in patients who attempt to defecate in a bed- 
pan. Surely, spasmodic stricture of the anal sphincter 
does not explain such cases. 

There is a condition which Dr. Fessenden Otis has 
termed urethrismus, or chronic spasmodic stricture, which 
is by no means infrequently seen, and which may result 
from various sources of irritation more or less remote. 
This condition may be due to chronic abscesses in and 
about the genito-urinary organs. Dr. Otis has reported 
a very interesting case of this kind, due to fistula and 
chronic abscess of the scrotum and testicles of long 
standing.* An interesting case of chronic spasmodic 
stricture due to fissure in ano, was reported several 
years ago by Dr. L* Bolton Bangs, a competent androlo- 
gist of New York.f 

Dr. Otis' remarks upon the subject of urethrismus 
are well worth repetition and they unquestionably prove 
that he is a keenly observant clinician % 

"The term spasmodic stricture has usually been 
applied to all temporary contractions of the urethra, 
which interfere in any degree with either the passage 
of instruments into the bladder, or the voluntary 
discharge of urine from it. As thus understood it has 
been described as varying in degree from the slight 
localized muscular spasm, which but momentarily 
arrests the progress of an ingoing instrument, to the 
firm, close contraction which more or less persistently 
resists its introduction in skilled hands, or from that 
which occasionally diminishes the strength of the out- 

♦Genito-urinary diseases, iF. N. Otis. 

+New York Medical Ri cord, January 26, 1888. 

^Syphilis and the genito-urinary diseases, 1888. 



URETHRISMUS. 59 

going stream of urine in urination, to that producing 
complete and enforced retention of urine. 

In whatever degree present in any case, it is claimed 
by all authorities to be characterized by its transient 
duration and its ready yielding to remedial measures. 
In accordance with this teaching, all permanent or 
habitual interference with urination or the passage of 
instruments (except in some rare instances complicated 
by vesical paralysis) must have an organic cause, and 
depend either upon the presence of an intra-vesical 
growth, an enlarged prostate, or of close organic 
stricture. It is also within the experience of many sur- 
geons, to have seen supposed subjects of close organic 
stricture, placed upon the operating table for the per- 
formance of external perineal urethrotomy, and, when 
fully anaesthetized, to astonish the operator by permitting 
the full sized exploratory staff to slip easily into the 
bladder. In other cases, the entire absence of that 
peculiar resistance to the knife, which the experienced 
surgeon recognizes when dividing cicatricial tissue, and 
the failure to locate with exactness the contracted point, 
will suggest to the memory of some that occasional 
patients, perhaps similarly affected, have not escaped so 
easily. 

Not unfrequently, persistent difficulty of urination, 
perhaps retention of urine requiring the habitual use of 
the catheter, has been observed by surgeons where no 
proofs of intra-vesical growths were present, and where 
the easy passage of an ordinary catheter precluded the 
idea of enlargement of the prostate or of close organic 
stricture. 

If it can be proven that purely spasmodic urethral 
contraction may, and not unfrequently does, present all 
of the important diagnostic features of the true close 
organic stricture, and farther, if it can be shown that 
polypoid and prostatic obstruction are often simulated 
by a chronic spasm of the acceleratior urinae muscles — 



60 STRICTURE OF THE URETHRA. 

producing obstruction and persistent closure of the 
membranous urethra, — then it will be conceded that 
failure to appreciate so important a complication will 
conduce to grave errors in diagnosis, terminating 
possibly in an operation for conditions which exist only 
in the mind of the surgeon." 

Dr. Otis cites a number of interesting but by no 
means uncommon cases in support of his theory, upon 
which he remarks as follows: "There are several points 
in the foregoing cases, (which I think may be fairly 
claimed to be types of a class), which coincide with the 
accepted characteristics of true, deep organic stricture, 
and which, if not appreciated, would lead of necessity, 
to an erroneous diagnosis, — such as was originally made 
in each one of the cases reported." 

These points are: i. A gradual diminution of the 
stream of urine. 2. Persistent frequency of micturi- 
tion. 3. Persistent resistance to the introduction of 
large instruments in the hands of skilled surgeons. 
4. Distinct grasping of small instruments, and a gradual 
toleration of instruments of increasing size, and in this, 
so perfectly simulating the behavior of true organic 
stricture, that the most skilled and learned surgeons 
have been deceived by these conditions. 5. The per- 
sistence, during a long period of years, of all the symp- 
toms which are recognized by authorities as character- 
istic of organic stricture. 

Dr. Otis then calls attention to the view entertained 
by Thompson, Erichsen, Bumstead, Van Buren, Keyes, 
Stilling, Dittel, and others, that the grand distinguishing 
feature of spasmodic, as contrasted with organic 
stricture, is the transitory character of the former 
variety. He then quite pertinently remarks as follows: 
"If this view is not correct (and that it is not, the cases 
cited go to prove) , it. will be readily seen that those 
surgeons who differentiate organic from spasmodic 
stricture by what is claimed to be the distinguishing 



URETHRISMUS. 6 1 

feature, viz: the transitory character of spasmodic 
stricture, are liable to fall into the grave error of treating 
a reflex urethral spasm for organic stricture. It is not 
at all likely that the cases I have reported, in which this 
error was made, are all the cases in which such errors 
have occured or are likely to occur. They are types of 
a class, and a large one too, which will necessitate the 
acceptance of other means of diagnosis than those now 
in vogue, before such errors can with certainty be 
avoided. First of these is the necessary knowledge of 
the normal calibre of the urethra in which symptoms 
of stricture are present; second, the size and condition 
of the external opening. If the measurements of these 
two points do not completely correspond, there is reason 
to believe that a reflex irritation may be present, which 
has the power of obscuring diagnosis. If there is a 
stricture, at or near the meatus urinarius, acquired 
through a previotis gonorrhoea or of congenital origin, con- 
tact of the urine with the sensitive mucous surface, {which 
is always present behind such a stricture} , or contact with 
exploring instruments, is capable of exciting a spasm at the 
membranous portioit of the tcrethra; a spasm which will 
often persist even when the patient is fully anesthetized, 
and will continue tip to the time that a complete division 
of the stricture is effected* 

It may, I think, be safely claimed that no reliable 
examination of the deeper urethra can ever be made 
while a stricture, or even an erosion, is present in the 
anterior portion of the canal. Inferentially then, no 
treatment of deep stricture, per se, should be attempted, 
until the complete freedom from organic contraction of 
the anterior portions of the urethra is established." 

The presence of the slightest contraction at any 
point as determined by the urethra-meter or bulbs and 
measurement of the circumference of the penis, is 
accepted by Dr. Otis as capable of producing reflex 

♦Italics mine. 



62 STRICTURE OF THE URETHRA. 

irritation, which may result in spasmodic contraction, 
which shall possess all the recognized characteristics of 
a deep organic stricture. 

It must at once be apparent to every experienced 
and practical surgeon, that Dr. Otis has given us in the 
foregoing remarks, a most valuable and practically 
reliable principle in genito-urinary surgery. So evident 
too, is the point involved, that one is inclined to wonder 
that it remained for Dr. Otis to discover. It is found 
for example, that in quite a large proportion of cases of 
penile stricture, a sound which is large enough to put the 
contraction on the stretch, either will not enter the bladder, 
or, if it does do so, it is only with great difficulty. A bul- 
bous flexible bougie of any size, will not enter at all, 
and even if a small one does succeed in passing the deep 
urethra, it is firmly grasped on withdrawal, the sensation 
imparted to the hand being not always deceptive to the 
expert, but to the surgeon of little or moderate experi- 
ence, constituting irrefutable evidence of deep organic 
stricture. Should a slight amount of organic linear con- 
traction be present to impart a distinct grating feel to the 
passage of the bulb over the contracted part, then indeed is 
the deceptive simulation of true, marked organic contraction 
complete. 

A recital of personal cases is often of value, but a 
repetition of a number of cases of a similar character 
is on the other hand apt to be tedious, especially if the 
principle, to elucidate which the report is made, is one 
that has come to be well recognized. It may however 
not be out of place for me to offer a single case with 
some very interesting features, as illustrative of a type 
which is met with great frequency. 

Case illustrative of chronic spasmodic stricture: W. B., 
Age, 29; Occupation, Architect. This gentleman had 
always been a very healthy man until twenty years of 
age, when he contracted a severe gonorrhoea, which 
lasted him for many months. This attack was followed 



URETHRISMUS. 63 

by a succession either of re-infections or exacerbations 
of a chronic urethritis. He finally got apparently well 
and remained so for several years. About four years 
before I saw him, he began to be annoyed by symptoms 
of stricture, following a fresh attack of urethritis. This 
was treated spasmodically, and maltreated constantly. 
One surgeon in particular had been so rough in his 
manipulations that it was feared a false passage had 
been produced. The patient stated that for two years 
he had had at short intervals, — usually after sexual or 
vinous indulgence, — complete retention of urine, the 
stream during the intervals of complete retention being 
very small and much time being required for the com- 
plete evacuation of the bladder. Relief of retention 
was always afforded by the passage of a small bougie 
with which the patient was constantly armed. Shortly 
before consulting me, he had been under the care of a 
surgeon who was enthusiastically trying to cure the case 
by electrolysis. I found on examination a meatus with 
a calibre of 20 Fr. Just within the meatus was a 
stricture of a calibre of 17 Fr. This was excessively 
irritable, and attempts at exploration were quite painful. 
At a depth of two and one-half inches was an irritable 
annular stricture of a calibre of 22 Fr. At three in- 
ches and a quarter was another stricture, evidently linear, 
which admitted only 17 Fr. The bulbo-membranous 
region was so tightly contracted that No. 4 Fr. was 
passed only with the greatest difficulty. As the patient 
was averse to an operation, I was compelled to do what 
I could by gradual dilatation, and succeeded in dilating 
up to No. 10 Fr. Attempts at further dilatation simply 
made a bad matter worse, and brought on an attack of 
retention which the patient himself relieved with the 
bougie. 

An operation on the anterior strictures was now 
consented to. I had informed the patient that I had 
formed the opinion that the deep stricture was spas- 



64 STRICTURE OF THE URETHRA. 

modic, but apprised him of the possible contingency of 
a perineal section in case it should prove to be organic 
and resisted dilatation after the anterior strictures had 
been removed. I performed internal urethrotomy, and 
remarked to the gentlemen who were present at the 
operation, that I expected to demonstrate what I had 
often shown in similar operations, that the deep stricture 
was spasmodic. Much to my chagrin I could not pass 
the deep urethra with the sound after the anterior 
urethra had been thoroughly freed from contractions. 
I invited my friends to the perineal section which I 
expected to perform as soon as the patient's consent 
should be gained. One week later 1 prepared the 
patient for the operation, and placed him in position, 
under anaesthesia. To the accompaniment of the 
friendly gibes of my professional friends, I remarked: 
"We will see if our stricture is still with us," picked up 
a 30 Fr. steel sound and fairly dropped it — so easily did 
it pass — into the bladder. I immediately passed larger 
sounds in succession up to 35 Fr. 

This patient got perfectly well and was married four 
months later. The sequel of the case was quite amusing 
as well as interesting. Some three months after his 
marriage I was called tD the patient's house, and found 
his wife suffering from a miscarriage due to the care- 
lessness of a physician who had been probing the 
uterus — to cure a supposed uterine trouble, with which 
the young woman supposed herself affected when cer- 
tain anomalous symptoms incidental to her pregnancy 
developed. The gentleman himself was lying in bed 
suffering from a terrific epididymitis, secondary to a 
virulent urethritis contracted two weeks before. The 
humor of the situation was complete when I set his 
mother-in-law at work making poultices for the young 
man's testiclar rheumatism. 

The epididymitis and gonorrhoea in this case recov- 



URETHRISMUS. 65 

ered very promptly, and there was no recontraction of 
the strictures when I last examined the urethra. 

In some instances, spasmodic stricture is a very ob- 
stinate and annoying obstacle to the treatment of 
organic disease of the canal. I have had under my 
observation several cases of this kind. In one of these, 
a gentleman of highly nervous temperament — I cut a 
contracted meatus, with the result of relieving the fre- 
quency of micturition, which was annoying the patient 
greatly at night. There was no contraction susceptible 
of operation in the remainder of the penile portion of 
canal, but there was a very slight organic contraction in 
the deep urethra. Such severe spasm was produced by 
efforts at dliatation that it was found impossible to in- 
troduce soft instruments of any considerable size into the 
bladder; steel instruments could not be introduced at all. 
As the amount of organic contraction was so slight, and 
moreover was located in the musculo-membranous re- 
gion, it did not seem advisable to perform any radical 
operation, particularly as urination was usually quite 
free and when it was not so the obstruction was readily 
relieved by anti-spasmodics and hot baths. I contented 
myself therefore, for a time, with the introduction of 
instruments up to the size of 24 French. I finally intro- 
duced an instrument of still larger size with consider- 
able difficulty and with the production of severe pain, 
although very little force was employed. The bougie 
was allowed to remain in the canal for a few moments 
and upon its withdrawal, I found much to my surprise, 
that it was so deeply indented by the nipping produced 
by the slight organic contraction combined with the 
intense spasm of the muscles, as to render it worthless. 
In numerous other cases I have noticed this same in- 
dentation of a soft instrument to a less marked degree. 

A case recently came under my observation of a 
physician in whom, although the urethra was appar- 
ently free from pronounced organic contraction and 



66 STRICTURE OF THE URETHRA. 

would at intervals readily admit a No. 18 English sound, 
there would occur great irritation and spasm of the 
deep urethra coincidentally with indulgence in alco- 
holics and sexual excess. At such times I found it diffi- 
cult to introduce a very small catheter into the bladder, 
although retention did not at any time occur. Irritable 
stricture of large calibre in a neurotic subject was the 
explanation of this case. 

The association of spasmodic contraction of the 
deep urethral muscles with disease of the kidneys has 
not, as far as I am aware, attracted special attention. It 
is an element however, of the painful and frequent mic- 
turition incidental to nephritic colic, stone in the kidney 
and pyelitis. I have a case now under observation in 
which there was marked urinary obstruction coincidental 
with an acute exacerbation of pyelitis, although the 
urethra had previously been entirely free from obstruc- 
tion. In such cases there maybe associated with the reflex 
spasm, more or less neuralgic pain of a reflex charac- 
ter in the back, groins, hypogastrium and thighs. I of 
course recognize the fact, that in these cases there ex- 
ists the special irritating factor of a morbid condition of 
the urine. 

DIAGNOSIS OF SPASMODIC STRICTURE. 

The diagnosis of spasmodic stricture is usually com- 
paratively simple, particularly in those cases in which 
retention comes on suddenly. It is obvious that the 
sudden occurrence of retention in a case of organic 
stricture, or other obstructive lesion of the genito-urin- 
ary tract, in which the stream of urine has been pre- 
viously only moderately lessened in size, must depend 
upon some complicating condition — either inflammation 
and congestion at the site of the organic lesion, spas- 
modic contraction of the cut-off muscle, or both condi- 
tions in combination, A certain degree of inflammation 
or congestion is to be inferred in every case of spas- 
modic retention of urine and requires due considera- 



DIAGNOSIS OF SPASMODIC STRICTURE. 67 

tion; the predominating element of spasm is, however, 
the principle feature. As a rule, in cases of sudden re- 
tention of this kind, there is a history of some one or 
more of the exciting causes which have been enu- 
merated. 

In determining the dependence of retention of 
urine upon spasm, it is necessary to remember that in 
by far the majority of cases there is some organic foun- 
dation for tiie condition. When, in the course of treat- 
ment for organic stricture of small calibre, retention 
suddenly occurs, the predominating condition is usually 
congestion or inflammation. The occurrence of acute 
urethritis during the course of marked organic stricture 
in apt to superinduce sudden retention. The condition 
in these cases, — although a spasmodic element exists, — is 
mainly congestion and inflammation at the site of the 
stricture, which produces sufficient swelling to com- 
pletely close it for the time being. Urethritis produced 
by the introduction of instruments brings about reten- 
tion in the same way. Cases of stricture of large cali- 
bre in which there is little or no obstruction to the pas- 
sage of urine, may suddenly develop retention from 
spasm. It is doubtful whether conges tio7i or inflammation 
alone cotdd produce closure of the canal in such cases. 

It is sometimes difficult to determine during instru- 
mentation of the canal, how much of the obstruction to 
the passage of instruments is due to organic contrac- 
tion, and how much to spasm. For example, after an 
instrument has passed a stricture of large calibre in the 
penile portion of the urethra, or an inflamed and irrita- 
ble meatus, it will be found to be obstructed in many 
cases as it enters the membranous region. A steel in- 
strument is less likely to be obstructed than a soft bulbous 
one, and the spasm is more likely to yield to steady and 
gentle pressure against it with the point of the sound than 
to a soft bulb. If there be organic contraction in slight 
degree at the bulbo-membranous junction, a steel instru- 



68 



STRICTURE OF THE URETHRA. 



ment small enough to pass the stricture in the anterior 
portion of the canal will, in all probability, slip by and 
fail to detect it. A large bulbous instrument will usually 
fail to pass altogether, but if a small bulbous bougie be 
introduced, it will be found that the spasm of the sur- 
rounding muscles, although insufficient to obstruct the 
passage of the instrument into the bladder, will at the 
same time pucker the stricture together so to speak, in 
such a manner that the shoulder of the instrument im- 
pinges upon it as it is withdrawn. The peculiar feel im- 
parted to the bougie and the sudden snap produced by the 
passage of its shoulder through the organic contraction, will 
determine the exact nature of the case. Fig. 32 shows in 
conventional outline the modus operandi of the diagnosis 
of stricture with the bougie a boule. 





Fig. 32. (After Culver and Hayden.) 

It will thus be seen that a comparatively small bulb 
may detect an organic contraction with predominating 
spasm in the deep urethra, where a very large steel sound 
would fail to perfectly outline it, or perhaps fail to detect 
it altogether. The peculiar sensation of elasticity im- 
parted to the instrument as it impinges against the por- 
tion of the urethra which is spasmodically contracted, 
will usually give an expert a tolerably accurate idea of 
the real condition of affairs. On account of the spasm 
which is usually encountered, there are very few individu- 
als indeed, in whom a stricture in the deep urethra cannot 
be demonstrated by the bulbous bougie. If, however, a very 
small instrument be passed, and carefully and slowly with- 



TREATMENT OF SPASMODIC STRICTURE. 69 

drawn, organic contraction may be readily excluded. The 
ordinary sound cannot be relied upon for a diagnosis. 

There are some exceptional cases of chronic spas- 
modic stricture, in which the real condition can only be 
demonstrated by the subtraction of all sources of irrita- 
tion, direct or reflex, after which the supposed organic 
stricture will disappear. 

TREATMENT OF SPASMODIC STRICTURE. 

Obviously, the first indication in the treatment of 
spasmodic stricture is to remove all predisposing causes 
as far as possible. Such conditions as the gouty and 
rheumatic diatheses require correction. General nerv- 
ous irritability and hyperesthesia may require nervine 
tonics, or sedatives and anti-spasmodics, or both, ac- 
cording to the special indications present. The prin- 
ciples of genito-urinary and sexual hygiene should be 
thoroughly impressed upon the mind of the patient. 
Once succeed in disabusing the patient's mind of 
the fallacious notion that his penis and testes constitute 
the. axis around which his earthly existence revolves, 
and the surgery of the case is much simplified. Every 
possible source of local and reflex irritation must 
be removed. This necessarily involves in the majority oj 
cases the ctire of organic lesions of the urethra. The urine 
should be kept bland and non-irritating by dietetic 
measures and the administration of alkaline remedies. 
Careful study should be given in each case to the degree 
of tolerance of the urethra for instrumental manipula- 
tions. The amount of irritability of the urethra and 
the degree of spasm excited by the passage of instru- 
ments is a fair criterion of the frequency with which 
theyishould be introduced in the treatment of organic 
stricture. 

When retention comes on as a consequence of 
spasmodic stricture, an attempt should be made to 
relieve the condition by derivation — with a view of re- 



70 STRICTURE OF THE URETHRA. 

moving possible congestion — and by anti-spasmodics. 
The passage of instruments should be avoided if possi- 
ble, as tending to increase irritation and spasm. The 
full hot bath, and morphia by the mouth or hypoder- 
mically should be depended upon as far as practicable. 
Very often the patient will succeed in passing urine 
while in the hot bath, which is both derivative and seda- 
tive. When it is found that these simpler measures fail 
to relieve, a small soft catheter should be carefully in- 
troduced — while the patient is in the bath if possible. 
If necessary, chloroform or ether may be given to the 
extent of full anaesthesia, for the purpose of relaxing the 
spasm and facilitating the passage of instruments. 
Whenever retention comes on in the course of organic 
stricture, it must be remembered that the accident is 
not due to the organic contraction per se, but to certain 
plus conditions, i. e., spasm, congestion and oedema of 
tissue in varying proportions. The relief of the reten- 
tion depends upon the subtraction of these plus condi- 
tions from the primary predisposing factor of organic 
contraction. The treatment of urethrismus is chiefly 
operative. After all sources of reflex irritation have 
been removed, the urethrismus disappears. 

CONGESTIVE OR INFLAMMATORY STRICTURE. 

This is usually a complicating condition rather than 
a pathological entity, being much less frequently met 
with as a prime factor in the case than spasm. Even 
the rare existence of congestive and inflammatory strict- 
ure as an essential condition is denied by many surgeons, 
but it would at least appear to be the main feature of 
a minor proportion of cases of urinary obstruction, with 
or without retention. This congestive or inflammatory 
obstruction may occur (i), as the result of occlusion of 
the urethra by extensive infiltration of the mucous 
membrane, peri-urethral connective tissue and the cor- 
pus spongiosum, in severe or virulent urethritis; (2) 



CONGESTIVE AND INFLAMMATORY STRICTURE. 7 1 

at the site of an injury to the mucous membrane pro- 
duced by instrumental or accidental trauma from within 
or without the canal; (3) as a consequence of acute 
and virulent urethritis affecting strictures of large 
calibre or congested and granular patches of the 
mucous membrane. 

Necessarily the most frequent variety of congestive 
or inflammatory stricture occurs in connection with or- 
ganic stricture. It is often a difficult matter to deter- 
mine in a particular case in exactly what relative propor- 
tion the elements of spasm and congestion exist. 

Some cases of congestive stricture exhibit a marked 
tendency to bleeding, either as a consequence of instru- 
mental interference, sexual indulgence, or in rare 
instances without apparent cause. I have noticed this 
symptom with especial frequency in syphilitics and in 
patients having a tendency to varices. 

THE TREATMENT OF CONGESTIVE OR INFLAMMATORY 

STRICTURE. 

The indications for treatment are the same as in 
spasmodic stricture — which is usually a complicating fac- 
tor — -with the exception that in cases in which it is be- 
lieved to be a prominent element or the predominating 
condition, the application of leeches in the course of the 
urethra, particularly in the perineal region, is advi- 
sable. 



CHAPTER IV. 



ORGANIC STRICTURE. 

TRAUMATIC AND CONGENITAL STRICTURE — STRICTURE IN 

THE FEMALE — VARIETIES AND LOCATION OF 

ORGANIC STRICTURE. 

Organic, permanent or fibrous stricture is that form 
in which the narrowing of the urethral calibre is due 
to an aggregation of organic tissue formation, and may 
be either congenital or acquired. It is most often ac- 
quired, and is most frequently met with between the 
ages of 24 and 45. 

Very rarely indeed does a stricture give trouble for 
the first time after the age of 40. It may occur at any 
time after the period of puberty. The frequency of 
stricture between the ages mentioned is easily explained 
by the fact that it is at this period of the life of the in- 
dividual that he is most subject to urethritis, — the most 
frequent cause of stricture. 

TRAUMATIC STRICTURE. 

Traumatic organic stricture may occur at any age. 
The youngest case which has come under my observa- 
tion was a boy of 13, who was operated upon several 
years ago by the late Dr. Hodgen, of St. Louis, who 
performed an external perineal section. In this case 
the stricture recontracted, — probably from neglect on the 
part of the patient, — and is now with difficult) 7 kept open. 
Another operation will eventually be required. Erich- 
sen records a case of traumatic origin in a boy of 11 
years of age. 

Traumatic stricture is usually located at the 

triangular ligament. It is at this point that the 

72 



PLATE II 




r--b 



-d 



MULTIPLE STRICTURE 



a:. Annular Cicatricial Stricture; b b, Dilated Portions of Urethra ; c, Callous Peri-ureth- 
ra] Tissue at Point of Deep Stricture: d, Sinuses in pars Prostatica. 
(After Dittel.) 



STRICTURE IN THE FEMALE. 73 

urethra is likely to be injured by blows or falls. A fall 
astride a hard object or a kick in the perineum is the 
usual cause. The bulbo-membranous urethra is caught 
between the impinging body and the sharp, knife-like 
lower border of the sub-pubic ligament, and a very slight 
degree of force may therefore produce permanent in- 
jury. It does not require a very great degree of violence 
10 completely sever the urethra in this situation. The 
pendulous urethra, on the other hand, is rarely involved 
in traumatic stricture on account of the difficulty with 
which it can be caught between two impinging bodies. 
No matter what the location of traumatic stricture 
may be, it is composed of cicatricial tissue, the extent 
of which depends upon the degree of destruction of the 
urethral walls, which has given rise to the stricture. 
Obviously such a stricture is the worst with which we 
have to deal. It is rarely amenable to dilatation, and 
usually requires a perineal section. 

URETHRAL STRICTURE IN THE FEMALE. 

It is obvious that the female sex enjoys relatively 
great immunity from stricture of the urethra. This is 
explicable by the shortness and simple structure of the 
canal and the extreme rarity of urethritis in the female. 
I have never seen but one case of the kind, and that 
occurred in a masturbator, probably as a consequence 
of laceration by the introduction of foreign bodies. 
Erichsen records a case occurring in a woman, but does 
not state the probable cause. Dr. Ely Van de Warker, 
however, has shown that stricture in the female is more 
frequent than is generally supposed, and has reported a 
number of interesting cases.* 

Otis has also asserted that stricture of the urethra 
is more often seen in women than is generally believed.f 
Symptoms, which in men would be at once attributed 



♦Journal of Am. Med. Ass'n, 1890. 

fTrans. Am. Ass'n of Andrology and Syphilology, 1891. 



74 STRICTURE OF THE URETHRA. 

to a stricture of the urethra, are in women attributed 
off-hand to an irritable bladder. It has been asserted 
that stricture may occur in lithaemic female patients 
independently of any infectious or inflammatory process 
and may require the same treatment as in men. 

CONGENITAL STRICTURE. 

The congenital form of s trie hire is rare, if we exclude 
narrowing of the meatus* The existence of congenital 
stricture below a point one-fourth of an inch from the 
meatus is denied by the majority of surgical authorities. 
If, however, we take into consideration the occasional 
occurrence of congenital atresia of a part or the whole 
of the urethra, the possible occurrence of localized con- 
genital narrowing of the canal seems logical. I have 
seen a number of cases of linear stricture of the pendu- 
lous portion of the canal which I believe to have been 
of congenital origin. One of my cases in particular was 
very striking. The stricture in this case was located at 
a point three inches within the meatus, and consisted of 
a thin membranous septum, imparting a sensation to the 
bulbous bougie as of a thin fibrous washer within the 
canal. This stricture was of large calibre and readily 
admitted a number 14 English sound. It was discovered 
accidentally during the passage of sounds for the relief 
of frequent nocturnal emissions. I had known the 
young man intimately since his childhood and am posi- 
tive that the history given me of the absence of traumatic 
and inflammatory causes was a truthful one. It may be 
asserted that such cases are traumatic and due to mastur- 
bation. This I admit to be possible, yet I deny the 
probability of such an explanation in the case just 
described and in some others which I have seen. In 
speaking of cases of congenital stricture, points of 
slight contraction which may be demonstrated in nearly 
all subjects are not included. 



CONGENITAL STRICTURE. 75 

Congenital stricture of the meatus is a relative affair, 
inasmuch as it is ri.QX.per se productive of discomfort, in 
by far the majority of cases. An individual with a 
meatus narrower than the average is not likely to be 
annoyed thereby, providing he never contracts gonor- 
rhoea. 

As has already been said in the chapter on anato- 
my, there is a wide variation in the size of the meatus 
in different individuals, and there is very frequently not 
only a narrow meatus, but a distinct linear contraction 
of the canal about one-fourth of an inch within it. 
When a urethra with such an external orifice becomes 
affected by inflammation, or when it is found necessary 
from any cause whatever to explore the urethra or blad- 
der, the meatus at once assumes a position of patho- 
logical importance, inasmuch as it is impossible to 
satisfactorily explore, — and more difficult, if possible, to 
thoroughly treat, — aurethra of moderately large calibre, 
if the meatus is narrow, even by the use of the urethra- 
meter. 

In order to determine the condition of the urethra, 
or to treat organic disease of the mucous membrane, 
the meatus must admit instruments of a size correspond- 
ing to the largest mean diameter of the canal. Obviously, 
when the normal calibre of the urethra is 38 French, it 
is impossible to satisfactorily explore or treat it, when 
the size of the meatus is only 30 French. Otis' urethra- 
meter, in the hands of the expert, has obviated the diffi- 
culty of exploration in such cases, but it is by no means 
as satisfactory or as safe an instrument for routine 
exploration as the bulbous bougie. Whenever, there- 
fore, there exists a suspicion of urethral, prostatic or 
bladder disease and the meatus is contracted, it should 
be enlarged by incision, to a sufficient size to admit an 
instrument which will thoroughly distend the canal. 

In by no means exceptional instances a contracted 
meatus of congenital origin has been known to induce 



76 STRICTURE OF THE URETHRA. 

reflex neurotic disturbances in very much the same 
manner as does a phimosed prepuce in some cases. Ir- 
ritability of the bladder with frequent micturition, and 
perhaps other more suspicious symptoms of stone, have 
been known to arise from this cause. I have met with 
a number of cases of this character, and one more inter- 
teresting still, in which atony of the bladder resulted. 
The connection between the vesical atony and the con- 
traction of the meatus was demonstrated by the success 
which followed meatotomy. 

A congenital narrowing of the meatus may be due, 
as already mentioned in connection with the anatomy 
of the urethra, to partial occlusion by a thin membran- 
ous septum at its inferior commissure, the fossa navic- 
ularis terminating in a pouch behind it. In others how- 
ever, the narrowing seems to be due to exceptional 
thickness of the tissues of the glans below the meatus. 
In the first of these conditions the meatus may stretch 
easily when instruments are passed. In the latter, 
however, the introduction of an instrument of suffi- 
cient size to distend the meatus, produces spasm, in 
some cases of the entire canal and in any event of the 
cut-off muscle: It will be seen therefore, that it is not 
alone the size of the meatus which is important, but its 
dilatability and its degree of tolerance of instrumenta- 
tion. Whenever, during the passage of an instrument, 
the meatus is drawn tightly about it in a thin white 
line, it is safe to conclude that that particular instrument 
cannot be introduced into the deep urethra without 
the exhibition of unwarrantable force. 

VARIETIES OF ORGANIC STRICTURE. 

According to conformatio7i, organic acquired stric- 
ture occurs in four principal varieties, viz.: (i) The 
first and simplest form is known as the linear stricture, 
the obstruction corresponding to that which would be 
produced by tying a narrow cord about the canal. 



VARIETIES OF ORGANIC STRICTURE. 



77 



The second variety is wider, and is known as the 
annular form, the condition being mechanically similar 
to that which would result from tying a flat band or piece 
of tape about the canal. (3) The third form, — which 
is divided by some authorities into several peculiar 
sub-varieties, — involves a considerable extent of the 
urethra in an irregular contraction, and is known as 
tortuous stricture. For practical purposes these three 
varieties are sufficiently distinctive. 

As regards their clinical features — stricture may be 
described as (a) simple and readily dilatable; (b) irrita- 
ble, — involving local hyperesthesia and hyperemia; (c) 
resilient or elastic ; (d) recurrent. This classification 
necessarily depends largely upon the behavior of the 
stricture under treatment. 

Linear strictures present them- 
selves in several different forms. 
In some cases there exists one 
or more membranous septa oc- 
cluding the canal to a greater or 
less extent. These are some- 
times known as bridle or pack- 
thread strictures. There may be 
a number of these bridles, the 
orifices of which may or may not 
correspond. In some cases the 
bands are transverse, and in 
others oblique, in direction. 
Their orifices may correspond to 
the center of the canal, or may 
be located at one side. Occas- 
ionally the septum or band has a crescentic form, 
and involves only a portion of the canal. The precise 
method of formation of these bridles and bands is 
open to question. It is not generally supposed that it 
is possible for inflammatory lymph to become exuded 
upon the surface of the mucous membrane. This ques- 




FIG. 34. 

Linear Stricture in the Anterior 
Urethra. (After Voillemier.) 



78 



STRICTURE OF THE URETHRA. 




tion would be difficult to settle, however, in the absence 
of abundant post-mortem evidences, It may be accepted 

as a possibilty hi cases in 
which the mucous mem- 
brane has been injured by 
instruments, or by chemical 
irritation. The theory has 
been advanced that in 
B some cases the bridles are 
due to the fusing together 
of the natural rugae of the 
flaccid canal. In some in- 
stances the condition re- 
sults from a tearing up of 
the valvular flaps of the 
mucous membrane by the 
careless introduction of 

Irregular Stricture, showing Bands and Bridles, instruments. In Others it 

(After Dittei.) Bridie shown at b. i s possible that a certain 
amount of atrophy of the submucous connective tissue 
and mucous follicles occurs, this giving rise to a loose 
flap of mucous membrane. That the natural folds of 
the mucous membrane may fuse together so to speak, 
and form part of a stricture mass, I firmly believe from 
conditions found in some cases of perineal section. 

Annular stricture may be due to thickening of, and 
interstitial deposit in the mucous membrane, or to sub- 
mucous inflammatory infiltration. I believe that insome 
instances of apparently annular stricture of large calibre — 
observed clinically — superficial thickening of the mucous 
membrane exists in the form of congested and granular 
plaques, at a point of normal relative inelasticity of the 
urethra. This lesion need not necessarily involve the 
entire circumference of the canal, although it appar- 
ently does so on account of the co-incident spasm, for 
just as soon as the bulbous bougie impinges upon such 
a sensitive spot, the urethra contracts down in front of 



VARIETIES OF ORGANIC STRICTURE. 



79 



the shoulder of the instrument, giving the same sensa- 
tion as it is withdrawn as would be imparted by a 
decided narrowing of the canal. Obviously it would be 




FIG. 36. 

Typical Annular or Band-Like Stricture. (After Dittel.) 

impossible to determine whether such a lesion involves 
the entire circumference of the canal or only a circum- 
scribed patch. 

Tortuous strictures are made to include all strictures 
above one-fourth to one-half an inch in width. They 
are irregularly contracted, i. e. } narrower at some points 
than at others, as a rule. The whole pendulous urethra 
may be involved, but always in a varying degree. The 
fact that an extensive tortuous stricture is narrower at 
certain points than at others is explicable upon the same 
grounds as the localization of congested and granular 
patches, and stricture of large calibre in the pendulous 
urethra, viz., the existence of normal points of relative 
inelasticitv at which the inflammatory process is necessarily 



80 STRICTURE OF THE URETHRA. 

more aggravated than in other portions of the canal. As 
already remarked, the formation of some tortuous stric- 
tures may perhaps be explained by the fusing together 

of the natural folds of the canal. If we admit the 
spiral or rifled form of the urethra in the flaccid condi- 
ition of the penis, it is conceivable that pronounced 
infiltration of the corpus spongiosum may permanently 
fix it in its tortuous conformation. 

The number of strictures is variable. It has most 
generally been accepted that stricture is usually single, 
but it will be found that in by far the majority of cases, — 
if the urethra be carefully explored, — more than one 
stricture exists. The surgeon who believes that a 
urethra which will admit a good-sized sound is neces- 
sarily free from stricture, is apt to recognize only the 
more marked cases occurring in the bulbo-membran- 
eous region, whereas if familiar with the occurrence of 
strictures of large calibre, he might discover by careful 
exploration in a given case, several strictures in the 
penile portion of the canal. Dr. Otis' investigations, 
while perhaps tending to slightly exaggerate the fre- 
quency and multiplicity of strictures, have certainly 
shown, not only that a stricture of large calibre may 
exist in cases in which the urethra will admit of a sound 
of good size, but that strictures of the pendulons urethra 
are much more frequently seen than has commonly 
been supposed. Some of the cases of so-called multiple 
stricture consist of irregular contractions of a long, 
tortuous stricture. 

Dr. Otis relates a most interesting case of combined 
perineal and internal urethrotomy in which fourteen 
separate and distinct contractions were found by him- 
self, and verified by other competent surgeons. In this 
case some of the strictures required several operations 
to complete the cure. The cut herewith presented (Fig. 
3j) shows the salient features of this case very clearly. 
In presenting this case before the New York Medical 



VARIETIES OF ORGANIC STRICTURE. 



81 



Journal Association* Dr. Otis demonstrated very clearly 
the diagnostic inaccuracy of the ordinary steel sound. 
No. 17 bulbous sound was first introduced by Professor 




FIG. 37. 

Dr. Otis' Case of Multiple Stricture. 

A. C. Post ; this was distinctly arrested at the points of 
stricture, at two and a half and two and three-quarter 
inches respectively. The obstructions were distinctly 
defined on withdrawal of the instrument, the result be- 
ing confirmed by several other prominent surgeons. 
Dr. Otis then introduced without force and painlessly 
a 24 Fr. conical steel sound through the strictures into 
the bladder. No. 25 Fr. was then passed quite as 
easily. Dr. Otis directed the attention of the society 
especially to the fact that while a 17 bulb readily de- 
tected the strictures, a No. 25 Fr. sound absolutely 
failed to detect them.f There is no fact in urethral 
surgery so readily demonstrable as this, yet most phy- 
sicians go right along in the old ruts, relying upon the 
sound for urethral exploration. And what is most ex- 
asperating is the fact that it is just such physicians, who 
perhaps have the confidence of the public and enjoy the 

*N - Y. Med. Journal, April, 1874 
fStricture of the Urethra. F. N. Otis. 
6 



82 STRICTURE OF THE URETHRA. 

patronage of a large clientele, that are obstructionists in 
the way of intelligent urethral surgery. It is decidedly 
unpleasant to have a patient in whom strictures have 
been detected by accurate exploration, inform one that 
Dr. X states that no stricture exists, and that this has 
been demonstrated by the passage of a sound. Yet 
this is a sample of the experience of the expert special- 
ist. The arbitrary and dogmatic opinions of the doc- 
tor whose armamentarium consists of a few sounds — 
and perhaps dirty ones at that,— are most pernicious in 
their influence upon the minds of the laity. To the lay- 
man, the situation often appears in a light by no means 
complimentary to the specialist, especially when, — as is 
often the case, — the general practitioner assures him 

that Dr. has suggested an operation or treatment 

of other kinds, merely for the sake of a fee. It does 
not seem possible that practitioners who pretend to be 
professional gentlemen could stoop to such means of 
self aggrandizement, yet such an experience has been 
the lot of many conscientious and competent men. So 
important do I consider this practical point, that I take 
great pains to demonstrate the relative diagnostic 
value of the sound and the exploring bulbs to my clini- 
cal classes. 

The amount of contraction in cases of stricture varies 
greatly, between those of large calibre, in which there 
is but superficial thickening with loss of elasticity of the 
mucous membrane, and those severe forms of long- 
standing: stricture in which the lumen of the urethra is so 
contracted as to resist the introduction of a tine bristle, 
even when the stricture is exposed post-mortem. The 
contraction is seldom sufficient to completely prevent the 
passage of urine. It has been claimed by excellent 
authorities, that in this sense, impermeable stricture 
does not exist. This, however, is probably incorrect, for 
it is conceivable that the urethra might be so completely 
destroyed from traumatism, that the resultant stricture 



VARIETIES OF ORGANIC STRICTURE. 83 

would close completely. The same is true of any organic 
stricture in case fistulae form behind it and divert the 
urine from its normal channel. Erichsen says, never- 
theless, that he has never seen or heard of a case of 
stricture which was completely impermeable to the pas- 
sage of urine, even when fistulae existed.* 

The explanation of the rarity of strictures imper- 
meable to urine is a very simple one. Every intelligent 
practitioner knows how difficult it is to heal a fistula in 
the tissues which communicates with secreting struc- 
tures, or a cavity containing materials which escape and 
enter the lesion. Urinary fistula, fistula in ano and sal- 
ivary fistula are familiar illustrations. The patency of 
urethral stricture is not only facilitated by the passage 
of the urine, but also by the fact that the mucous mem- 
brane is usually intact — or at least in part. The in- 
flammatory deposit, as a rule to which there are few 
exceptions, occurs in and beneath the mucous mem- 
brane, and produces obstruction by pressure upon it, 
instead of by fusing the opposing surfaces of the ureth- 
ral walls together. Just so long as an intact strip of 
mucous membrane, however narrow, exists in the track 
of even the most tortuous stricture, just so long is it 
permeable — strictly speaking. 

Strictures impermeable even to instruments are 
also very, rare, particularly in the practice of surgeons 
who exhibit sufficient patience, gentleness and skill in 
instrumentation. A stricture should not be pronounced 
impermeable becattse at one, or perhaps a dozen attempts it is 
found impossible to pass an instrument, for soo7ier or later, — 
particularly if appropriate general measures of treatment 
be instituted, — an instrument will usually be found to 
pass, and no matter how small it may be, the successful 
passage of a bougie at once gives the surgeon almost com- 
plete control of the case. The most competent androlo- 
gist may fail to pass a stricture, but it must be remem- 

*"Science and Art of Surgery," vol. ii, p. 852. 



84 STRICTURE OF THE URETHRA. 

bered that the impermeability of the stricture at one 
end of the bougie may mean a lack of tact or patience 
at the other. 

THE LOCATION OF STRICTURE 

The location of stricture nas been the subject of 
much controversy. Dr. Otis' investigations in particular 
have modified in certain quarters the existing ideas of 
the relative frequency of stricture at different points 
in the urethra. That the views of Otis have not been al- 
lowed to pass unquestioned goes without the saying. The 
intellectual combat between Dr. Otis — at that time my 
superior in the genito-urinary service of the New York 
Charity Hospital — and my friend, the late Dr. 
Henry B. Sands, is one of the most vivid recollections 
of my hospital days. 

Until recently the dicta of Sir Henry Thompson 
and others of his school have been universally accepted 
upon the location of stricture. Thompson found in 
320 cases of stricture, — examined clinically, — 212 which 
were located at the bulbo-membranous junction, 
51 in the spongy portion of the canal, at variable points 
between one inch anterior to the opening of the tri- 
angular ligament, and 2^2 inches posterior to the 
meatus, and 54 at the meatus or within 2}^ inches pos- 
terior to it. In 270 cases examined post-mortem, he 
claimed a decided preponderance of stricture in the 
bulbo-membranous region, which he describes as the 
space included between a point one inch anterior to the 
triangular ligament, and another % of an inch poster- 
ior to it.* H. Smith examined 98 preparations of stric- 
ture in the London Museums, and found only 21 in the 
membranous urethra, the other yy being anterior to it. 
The majority of the latter were situated in the bulbous 
urethra or just in front of it. Otis claims, and I think 
correctly, that the condition is most frequently found in 

""'Stricture oi the Urethra." Sir Henry Thompson. 



THE LOCATION OF STRICTURE. 85 

the penile portion of the canal. It is obviously impossi- 
ble for the Thompson and Otis schools to arrive at har- 
monious conclusions as long as their standards of stric- 
ture and methods of exploration remain so widely dif- 
ferent. Post-mortem evidence is only relatively val- 
able. The surgeon who reasons from clinical experi- 
ence and skillfully uses the urethrameter and bulbs, can 
never agree with Thompson, and must acknowledge the 
accuracy of Otis' methods, even though he may con- 
sider the conclusions of the latter somewhat overdrawn. 
It has been my experience that the most frequent site 
of stricture appears clinically to be at the meatus or 
just within it, most of these cases however being con- 
genital. The next most frequent point is the junc- 
tion of the bulb and fossa navicularis, or just posterior 
to it. z. e.y 2y 2 to 3 inches from the meatus The next 
most frequent location is the bulbo-membranous junc- 
tion and the next about one inch anterior to it. It 
seems to occur with varying frequency in the inter- 
mediary portions of the canal. 

Otis found in 258 strictures 52 in the first % inch 
of the urethra; 63 in the next inch, i. e. from % 
to \% inches ; 48 from 1% to 2%.\ 48 from 2%. to 3^; 
19 from 3X to 4%\ 14 from 4% to 5^; 8 from 5^ to 
6% ; 6 from 6% to y%* 

In another series of 357 strictures only 5 were be- 
low 5 inches from the meatus. Bevan found that 89. 
per cent., or 399 strictures, in one of his own series, were 
anterior to 4% inches. 

As Otis remarks, it will be found that strictures 
occur, as might naturally be expected, with greatest 
frequency where the inflammation begins the earliest 
and rages the hottest, the frequency gradually dimin- 
ishing in the deeper portions of the canal. 

From a clinical standpoint I have come to regard 
stricture as any condition of the urethra which is capable 

♦Stricture of the Urethra. 1882, 



86 STRICTURE OF THE URETHRA. 

of producing friction, by oostructing the flow of urine — 
to however slight an extent — providing said obstruction 
and friction is productive of pathological disturbances, or 
— if the latter have already begun, — tends to perpetu- 
ate them. A point of normal contraction, or relative 
inelasticity, becomes a stricture only when the urethra 
assumes a pathological state ; the previously normal 
lack of distensibility is then of great pathological and 
surgical importance, and its removal may be impera- 
tively necessary. 

No one who has not given this subject special study 
can realize the difficulty of forming an accurate esti- 
mate of the relative frequency of stricture in the vari- 
ous parts of 'the canal. The different standpoints of 
observation give widely varying results. As already 
indicated, Otis and Thompson can never be nearer 
together than they are to-day, unless both should accept 
the same standard as a criterion of stricture, and use 
the same methods of exploration and diagnosis. The 
Weir-Sands faction, with its normal points of contrac- 
tion in the pendulous urethra, certainly cannot become 
reconciled to the teachings of Otis. I know of several 
excellent men with whom I have conversed, whose 
methods of reasoning are so widely apart that each 
stamps the other as an ignoramus. One begs the ques- 
tion, by accepting the views of Otis that a urethra 
should take a sound of a calibre proportionate to the 
dimensions of the penis, and the other entirely over- 
looks the question at issue, by the assertion that, " that 
kind of strictures can be found in healthy men." I once 
related a case of congenital stricture in the pendulous 
urethra to a prominent surgeon in this city, and he 
asserted that the patient could not possibly have a 
stricture if, as I said, he could take a thirteen English 
sound. I presume that there are many skillful men who 
would claim that a patient who can take a thirty to 
thirty-five French sound has no stricture Yet a patient 



THE LOCATION OF STRICTURE. 87 

may take a forty French sound, and the case still de- 
mand urethrotomy. Number thirty may pass smoothly 
by an obstruction, which a number fifteen bulb will easily 
demonstrate. 

Believing, as I do, that any point of contraction or 
inelasticity in the urethra, in the presence of a path- 
ological condition of the mucous membrane, constitutes 
a stricture, I can unhesitatingly reiterate my firm convic- 
tion that stricture of the urethra is most frequent in the 
pendulous portion of the canal. If care be taken to 
exclude the element of deep urethrismus, — which ex- 
clusion is not as easy as some authors would have us 
believe, — the proportion is, I think, at least ten to one. 

That great variance of opinion exists upon this 
point is well known, and Bumstead and Taylor long 
ago called attention to the fact that there could be no 
harmony of results between those who studied the sub- 
ject upon the living and those whose estimates were 
formed entirely upon observations of the cadaver. 
Folet, in 1857, called attention to the frequency of 
fibrous stricture in the pendulous urethra, and its com- 
parative rarity in the bulbo-membranous region. This 
author claimed that deep obstruction existed in all cases 
of stricture of the spongy portion, but that the deep 
stricture was nearly always spasmodic and secondary 
to the trouble in the anterior portion, of the canal. In 
1866, Verneuil coolly appropriated Folet's thunder 
and expressed essentially the same views and in very 
nearly the same language. Otis, writing at a later 
period, while not so radical as his French predecessors, 
has promulgated similar views, but in a much more com- 
prehensive and thorough manner. The relation of ureth- 
rismus to reflex irritation more or less remote, as shown 
by Otis, is one of our most important contributions to 
the literature of genito-urinary pathology, and is decid- 
edly complimentary to the genius of American surgery. 

In estimating the frequency with which deep spas- 



88 STRICTURE OF THE URETHRA. 

modic stricture complicates obstruction in the pendu- 
lous urethra, an important source of fallacy exists, to 
which I will call attention, although at the risk of repe- 
tition of some points previously outlined: While a deep 
stricture may be demonstrated in nearly if not all cases, 
by instrumentation, it does not necessarily follow that 
such deep strictures exist at other times. A tender 
urethra resents a foreign body quite as vigorously as 
does the eye, and as soon as the sound touches a ten- 
der spot or sensitive stricture — even of large calibre — 
in the pendulous urethra, a pronounced reflex contrac- 
tion is observable throughout the entire canal, which 
is of course, most pronounced in the deep portion. A 
spasm of the pendulous portion is not usually regarded 
as of importance; indeed, some surgeons discredit it 
altogether. I have found, however, that the spongy 
portion often contracts so firmly about the sound that 
it is felt to be firmly grasped during withdrawal all 
along the canal. This clonus in the pendulous urethra 
is of great assistance in diagnosis, as it serves to force 
diseased portions of the canal down in front of the 
shoulder of bulbous instruments of a calibre much 
smaller than the stricture will readily admit. Thus 
it often happens that a good-sized sound will pass by 
obstructions upon which quite small bulbs will catch. 

In some cases, as already stated in the discussion of 
spasmodic stricture, deep spasm exists more or less con- 
stantly; but I believe that in many of these cases there 
is an actual organic change at the site of the spasmodic 
stricture; this maybe true organic deposit, an erosion, 
or a congested and granular patch. Under such cir- 
cumstances it is often very difficult to determine, even 
approximately, the proportionate relation of spasm to 
organic lesion. Oftentimes the true condition of affairs 
can only be determined by subtracting the sources of reflex 
spasm in the anterior urethra by urethrotomy . 

The prostatic portion of the urethra is never in- 



THE LOCATION OF STRICTURE. 89 

volved in true stricture so far as known. Thompson 
says on this point: " I may confidently assert that there 
is not a single case of stricture of the prostatic portion 
of the urethra to be found in any of the public museums 
of London, Edinburgh, or Paris."* 

The immitnity of the prostatic portion of the canal is 
explicable from the following considerations: (1) 
Because of the rarity of extension of the acute inflam- 
mation to its mucous membrane; (2) Its distance from 
the primary point of infection and consequent exhaus- 
tion of the virus by the time the inflammatory process 
reaches the deep urethra. This gradual exhaus- 
tion of virulency is due to the resistance of the tissue ele- 
ments — upon which resistance the inherent tendency of 
urethral inflammations to recovery depends. The 
gradual exhaustion of virulency of infectious processes 
as they travel downwards from the meatus cannot be 
disputed. (3) The close adherence of the mucous 
membrane to the muscular tis'sue of the prostate; (4) 
Perfect flushing of the mucous membrane during 
urination; (5) The constant barrier to the passage of 
poisonous secretions afforded by the contraction of 
the cut-off muscle; (6) A comparative degree of insus- 
ceptibility of the prostatic region to ordinary irrita- 
tions and infections. 

♦Thompson. Op. Cit. 



CHAPTER V. 



PATHOLOGICAL LOCALIZATION AND MORBID ANATOMY OF 

STRICTURE. 

The predilection of stricture for different portions of 
the canal has not, it seems to me, been satisfactorily — 
or at least clearly — explained by the various authorities 
upon the subject. The explanation usually given for the 
relatively greater frequency of occurrence of stricture 
in various portions of the canal, more particularly in 
the bulbo-membranous region, is that there is in these 
situations a greater amount of the erectile tissue, and a 
more marked tendency to localization of inflammatory 
processes than in other portions of the canal. 

There are several points to be considered in the 
explanation of the occurrence of stricture in any partic- 
ular location, and in some instances there are certain 
special elements in its production which are worthy of 
attention. 

Acquired strictures at, or just within the meatus 
are favored by the existence of congenital narrowing 
at this point. There is constant obstruction to the pas- 
sage of urine and the friction thereby induced, inevitably' 
enhances inflamation. There is, moreover, a tendency to 
pocketing of secretions behind it, and these secretions — 
primarily acrid in the case of virulent products of in- 
flammation — are likely to decompose very speedily and 
aggravate the existing inflammation. The introduction 
of the nozzle of the ordinary syringe in injecting the 
urethra, necessarily produces considerable irritation 
when the meatus is very narrow. These considerations 

explain the frequency with which acquired stricture is 

90 



PLATE III. 













VW^C 



\ 



■?k 



jiff m ,;/ 




Old Stricture of Pendulous Urethra showing- Diverticula and Bands at Strictured Point 
with Diverticula of the Bladder. {After Dittel.) 



PATHOLOGICAL LOCALIZATION OF STRICTURE. QI 

found just within the meatus. Long nozzled syringes 
often produce stricture at a little distance within the 
meatus by the frequent impact of the point of the in- 
strument against the inflamed mucous membrane. At 
such a spot of irritation the inflammation will necessarily 
become localized and chronic. 

The relative dilatation of the bulbous portion of the 
spongy urethra and of the fossa navicularis undoubtedly 
favors the retention of a small quantity of urine and of 
pathological discharges at these points, but this element 
in the causation of stricture is not very important until 
actual obstruction by inflammatory thickening of the mu- 
cous membrane occurs just in front of the dilated point. 
Under ordinary circumstances these expanded portions 
of the urethra are thoroughly flushed out from time to 
time by the urine. When, however, stricture begins to 
form there will inevitably be a small quantity of decom- 
posable fluid left in the canal in these situations. I think 
however, that this condition assumes little importance 
until the stricture becomes very thick, as the residual 
urine is not allowed to remain undisturbed for any great 
length of time. The urethra is relatively somewhat ex- 
panded just behind the juncture of the fossa navicularis 
with the spongy urethra, and at this point also similar 
conditions prevail. 

Strictures produced by injury to the canal during the 
passage of instruments necessarily occur at the site of 
the lesion thereby produced. Inasmuch as the principal 
obstruction to the careless passage of instruments, even 
in the normal urethra, is found at the opening in the 
triangular ligament — i. e. the bulbo-membranous junc- 
tion — it is at this point that such strictures are most apt 
to be found. 

Traumatic strictures produced by falls and blows 
upon the urethra, correspond to the seat of the injury. 
It is very difficult however, to catch the pendulous ure- 
thra between two impinging bodies, unless it is done 



92 STRICTURE OF THE URETHRA. 

with deliberate intent to produce injury. In the case of 
the deep or fixed urethra, however, injury is very readily 
produced by falls and blows upon the perineum. Strict- 
ures produced in this way occur most frequently at the 
bulbo-membranous junction, for, as already stated, this 
point corresponds with the opening in that tense, fibrous 
septum, the triangular ligament, and with the sharp 
lower border of the subpubic ligament; this latter 
structure is of a semi-cartilaginous consistency, and its 
edge is almost as firm and resisting as would be a nar- 
row border of bone. It is between this hard tissue and 
the impinging body that the urethra is usually caught 
in injuries of the perineum, and it takes but slight force 
to produce sufficient injury to the canal to result in 
traumatic stricture. Comparatively slight force may 
sever the urethra completely. Injuries unnoticed in 
early life may later on produce organic stricture. These 
traumatic strictures are on the average the worst variety 
with which we have to deal. 

The location of strictures due to the introduction of 
strong chejnical or caustic substances into the urethra , may 
be determined by the same normal anatomical condi- 
tions, as in the case of ordinary virulent urethritis. They 
may, on the other hand, occur at the point chiefly 
affected by the caustic or chemical substance. 

Foreig7i bodies in the urethra may produce localized in- 
flammation — and perhaps ulceration — which determines 
the site of a subsequent stricture. Most often a foreign 
body lodges in one of the dilated portions of the canal. 
Under such circumstances the foreign material produces 
the most pressure and irritation, at that point in the mu- 
cous membrane at which its outward passage with the 
flow of urine is obstructed. 

Injury incidental to the occurrence of chordee, is often 
responsible for the localization of stricture. This con- 
dition interferes with the normal distensibility and elas- 
ticity of the urethra, and during erection produces a 



PATHOLOGICAL LOCALIZATION OF STRICTURE. 93 

strain upon the tissues of the corpus spongiosum and 
theurethraat some particular point, or points. The point 
of greatest convexity of the curve produced by the chor- 
dee is, as a rule, the point at which the greatest strain 
is experienced. The irritation produced by this strain- 
ing of the tissues is apt to induce the localization of 
stricture at this point. In some instances the corpus 
spongiosum or mucous membrane of the urethra yields 
to the tension and is lacerated to a greater or less ex- 
tent. This may be produced by the patient forcibly 
bending the penis with the fatuitous idea that rupture 
of the chordee will cure his gonorrhoea. I believe how- 
ever, that in marked cases it may resy.lt from frequent and 
vigorous erections, the occurrence of laceration being unrec- 
ognized, save perhaps in some cases in which the patient calls 
tne attention of the surgeon to the fact that there has been 
more or less hcemorrhage during the night as a result of the 
chordee. The corpus spongiosum being inelastic, vigor- 
ous erections may produce slight traumatisms here and 
there in the canal in the absence of recognizable chor- 
dee. This, in my opinion, isa frequent cause of stricture. 
Under the circumstances mentioned the subsequent 
stricture occurs at the site of the injury of the tissues. 
M. Desnos has recently called attention to slight 
traumatisms of the urethra during erection, as a cause 

of stricture.* In my lectures for ten years past, I have 
claimed that slight injuries of the mucous membrane, — 

and perhaps, of the corpus spongiosum — frequently occur 
during urethritis, as a result of erections while the elas- 
ticity of the spongy urethra is impaired by plastic exu- 
date. These injuries are, of course, most likely to oc- 
cur if chordee be present, or if intercourse be attempted ; 
but may happen when neither circumstance prevails. 
It is not necessary to "break the chordee"to produce 
them. Whenever any appreciable quantity of blood 
appears in a gonnorrhceal discharge, such minute trau- 

*Annales des Mai. des urganes Genito-Urinaires. 



94 



STRICTURE OF THE URETHRA. 



matisms may be inferred. These slight injuries often 
form the groundwork for future stricture building. 




Fig. 38. Casts of Supposedly Normal Urethrae. (After Sands. ) 

By far the most important element in the determin- 
ation of stricture at special points in the urethra is, the 



PATHOLOGICAL LOCALIZATION OF STRICTURE. 95 

existence of certain normal anatomical peculiarities of the 
structure of the canal. These are the chief bone of con- 
tention among the warring factions whose casus belli 
is the question, to cut or not to cut. It has been shown 
by Weir, Sands and others that there are certain points 
of narrowing in the spongy portion of the canal which 
have been termed by them normal contractions, these be- 
ing distinct from the normal points of contraction us- 
ually recognized, namely, the meatus, the bulbo-mem- 
branous junction and the point of union of the spongy 
urethra with the fossa navicularis. This description is, 
it appears to me, somewhat misleading. The urethra 
is an elastic tube susceptible of considerable dilatation. 
Its elasticity, however, is not uniform throughout, but 
as a consequence of sparsity of elastic tissue, with a pre- 
ponderance of connective and fibrous tissue in the erec- 
tile structure of the corpus spongiosum, and a deficiency 
of areolar tissue beneath the mucus membrane, there 
exists atvarious points in the canal relative inelasticity 
and limited dilatability of the urethra. 

It is well known that in certain portions of the 
canal relative inelasticity and limited dilatability, are due 
to certain anatomical peculiarities of the surrounding 
structures. For example, at the opening in the triangular 
ligament, the urethra is not only narrow, but is sur- 
rounded by dense and unyielding tissues. The meatus 
is comparatively inelastic in most individuals, even 
when it cannot be said to be congenitally contrac- 
ted. The corpus spongiosum is a little thicker at the 
junction of the fossa novcularis with the spongy urethra 
and at the junction of the latter with the bulb. At these 
various points moreover the areolar tissue beneath the 
mucous membrane is disproportionately scanty and the 
latter is more closely applied to the tissues upon which 
it rests. It would seem also that, as there is normally 
more strain at these points of narrowing than at an) 7 
other portion of the canal, the urethra is here rein- 



g6 stricture of the urethra. 

forced by an increased density of fibro-connective 
tissue. 

In explaining the localization of stricture, we will 
take as our point of departure the fact that the urethra 
is a dilatable tube, the elasticity of which varies at dif- 
ferent points in the canal. Through this tube, water at 
a certain pressure and in a certain volume, is forced at 
more or less frequent intervals. Obviously, the greatest 
friction is produced at the various points of normal con- 
traction and relative inelasticity. Against the strain and 
friction produced at these points nature has provided a 
certain amount of reinforcement of tissue, and under nor- 
mal circumstances, with a healthy mucous membrane, 
this pressure and friction does not produce any injury. 
When however the canal is inflamed, as in acute urethritis, 
its lumen and elasticity are decreased. Urine is nevertheless 
pumped through the tube in as great a volume and with 
as great frequency as under normal circumstances, pro- 
ducing by its mechanical pressure, friction and chemical 
effects, considerable irritation, as is evidenced by the 
consequent pain and smarting. Obviously, the greatest 
amount of irritation from friction, chemical action and 
pressure occurs at the points of relative inelasticity of 
the canal, and as a consequence it is here that inflam- 
mation tends to localize itself, and persists, — perhaps 
long after the remainder of the mucous membrane has 
returned to a condition to a greater or less degree 
approximating the normal This continual friction and 
irritation is interpreted by the controlling centers and 
nervous supply of the part as a demand for reparative 
material, and as a consequence there must inevitably be 
more or less plastic deposit at these points. This plastic 
deposit is a conservative effort on the part of nature, to pre- 
vent injury by the increased strain and irritation and to secure 
physiological rest. Unfortunately, however, this conserva- 
tive process is in these instances misapplied, for if 
complete absorption does not occur, the exuded in- 



PATHOLOGICAL LOCALIZATION OF STRICTURE 97 

flammatory material remains, organizes, contracts and 
constitutes a stricture. 

The existence of the points of relative inelasticity 
referred to also explains abraded, congested and granu- 
lar patches of the mucous membrane in all instances 
in which they are not due to the frequent contact of in- 
struments. The relatively greater amount of friction at 
such points tends to produce abrasion of the mucous mem- 
brane and removal of its epithelium, more frequently 
than at any other parts of the urethra. Rapid remo- 
val and reformation of cells results in impaired vitality 
and avicous habit of cell formation. This is one of the 
most important factors in chronic urethritis. 

To sum up: The process of formation of strichtre may 
be illustrated by a rubber tube of delicate structure and 
small calibre ', through which water is pumped in a certain 
volume at more or less frequent intervals, and at a certain 
degree of hydrostatic pressure. 

If this tube be compressed at certain points, or if it be 
tied in such a manner that, although not compressed, it is 
prevented from distending perfectly under the strain of the 
water, it is easy to see that it is at the point of obstruction 
that the tube is "most apt to give way, or after a time, to 
wear out. If the lumen of the tube be diminished, the 
volume of water that is poured through it remaining 
the same, the strain upon its texture at these points will 
be greatly increased and it will give way much sooner. 
When, as a consequence of localization of inflammation 
upon the surface of, and infiltration of the areolar tissue 
beneath the mucous membrane, it becomes less elastic, 
as is the case when congested and granular patches oc- 
cur from any cause whatever, there exists the same rel- 
ative inelasticity and obstruction, and as a consequence 
a deposition of young connective tissue with result- 
ing formation of stricture is apt to occur sooner or 
later. The friction produced by the urine is the prin- 
cipal explanation for the steady increase in thickness 



98 STRICTURE OF THE URETHRA. 

and contraction of organic strictures. The extent of 
the stricture deposit depends on the degree of strain 
and friction present. 

The physiological and biological elements in the loc- 
alization of stricture must not be forgotten, — the vicious 
habit of cell formation already alluded to is of great 
importance: In the course of acute urethritis, there 
is a tendency to rapid formation of epithelium of a low 
grade. This is a reparative, a conservative process, but 
unfortunately a certain biological law comes into play 
here, viz : In inverse proportion to the degree of differen- 
tiation of cells is their rapidity of proliferation, and their 
tendency to degeneration. The consequence of this law is 
an erosion at the point of friction, and secondarily, a 
plastic deposit to resist strain. Comment upon this is not 
necessary. The subsequent metamorphosis into fibro- 
connective tissue of this deposit is well known. In the 
pendulous urethra especially, — andproDably, also in the 
fixed portion — the plastic deposit may absorb, but the 
friction remains and a gleet is- often kept up. The 
points of normal contraction and relative i7telasticity have 
now become of pathological importance. 

Now, I wish to ask at this juncture, what difference 
it makes whether these points were primarily present in the 
canal as normal conditions or not, as regards their surgical 
relations from the standpoint of treatment . The ques- 
tion is not, whether they are adventitious, as claimed 
by Otis, or normal as claimed by Weir and Sands, but 
what are their relations to the abnormal state of the canal ? 
I believe that the difference between the two conditions 
is one of degree and not of kind, and I can see no logic 
in the dispute on either side. 

From what has been said, I think — contrary to the 
usual opinion — that the direct relation of stricture to the 
severity of the primary urethritis may be clearly seen. 

It is a self evident proposition that if what I have 
said regarding the relation of stricture to friction be 



PATHOLOGICAL LOCALIZATION OP^ STRICTURE. 99 

true, the same holds good with relation to granular, con- 
gested and eroded patches in the canal. I believe 
moreover, that within certain limits the indications for 
treatment may be the same. In addition to the element 
of friction in producing stricture and other lesions of 
the urethra, I acknowledge a varying degree of import- 
ance of retained infectious and inflammatory products 
at points of narrowing 

Regarding the importance of the element of fric- 
tion, Otis says: 'It is only necessary to establish the 
fact that the normal resiliency of the urethra is dimin- 
ished at a given point, to prove that, during micturition 
a perturbation of the stream must occur at such point, 
even if it is not sufficient to attract attention in any way. 
Hence the slightest contractions assume an importance 
which could not be inferred from the apparent freedom 
from trouble in passing the uririe. They establish a 
localized point of friction, and of necessity, an increased 
excitement in the vessels of the part, possibly only 
enough to disturb the complete elaboration of epithelial 
material, and to cause a shreddy deposit to take the 
place of the clear normal secretion, and this may occur 
with very slight, or without the least abnormal sensa- 
tion being present. The presence of the mucoid shreds 
in the urine may be the only evidence of commencing 
trouble. But a permanent point of friction once estab- 
lished, greater than the natural conservative power of 
the surrounding parts is able to counter-balance, ob- 
struction is increased by the natural aggregation of 
plastic material at the point of irritation. In this way 
the tendency to recovery iscombatted and a permanent 
point of inflammatory action is established. 

Thus the difficulty, which commenced simply as an 
obstruction to the resiliency of the urethral walls, pro- 
gresses certainly and naturally, to the point of narrow- 



100 STRICTURE OF THE URETHRA. 

ing, to a greater or less degree, the calibre of the ureth- 
ral canal."* 

When the views of Dr. Otis first appeared, they 
gave rise to much opposition. Among those who most 
vigorously combatted the teachings of Otis, was my la- 
mented friend, the late Henry B. Sands. Among other 
arguments, Dr. Sands presented some very carefully 
prepared casts of inferentially normal urethrse, which 
showed great variation of calibre. What strikes me as 
most peculiar was the controversy on the question of 
the normal or abnormal character of many of the penile 
strictures as diagnosed by Otis. Taking into consider- 
ation the purely mechanical effects of stricture of 
the urethra, it is difficult to understand how quibbling 
was possible. To illustrate this point we will select one 
of Dr. Sands' own cuts. (Fig. 38.) What difference in 
the results and in the line of treatment could be main- 
tained between a gleet perpetuated by the normal points 
of friction in such urethrae, and a gleet perpetuated by 
acquired stricture? Sooner or later, true adventitious 
deposit occurs and the point of normal, relative indis- 
tensibility merges into an acquired neoplastic contrac- 
tion. Points of relative inelasticity or contraction and 
points of of acquired contraction may be precisely the same 
from a clinical standpoint, in the presence of a pathologi- 
cal condition of the mucous membrane. The cure of the 
case demands their removal, independently of their 
origin. 

*Otis Op, Cit. 



CHAPTER VI. 



MORBID ANATOMY OF STRICTURE. 

When urethritis becomes localized at any point in 
the canal, there results an extension of the process to 
the sub-mucous tissue, if this has not already occurred, 
or there is an increase in a pre-existing peri-urethral 
thickening. As Finger, Halle, Wasserman and others 
have shown, this is due to a sub-mucous infiltration of 
embryonal cells which soon forms a zone ot peri-urethral 
sclerosis, more or less dense. This may or may not at 
the beginning, comprise a distinct thickening of the cor- 
pus spongiosum. This process constitutes the debut of 
stricture, and is the condition most frequently detected 
by the bulbs or urethrameter in chronic urethritis. Ob- 
viously, it is upon the loss of elasticity at the affected 
point, that the detection of the lesion depends. The 
same loss of elasticity explains the symptoms and tend- 
ency to increasing growth of the stricture. 

In some instances there will be found a slight thick- 
ening of the mucous membrane with little or no sub- 
mucous proliferation of connective tissue, the epithelium 
being more or less denuded and covered with muco- 
purulent secretion. The follicles of the urethra at 
this point are dilated, thickened and in a condition of 
hyper-secretion. When the process has gone a little 
further the mucous membrane is thickened, congested, 
and perhaps covered with fungous granulations at the 
diseased spot, and there is more or less infiltration and 
thickening of the submucous connective tissue and the 
structure of the corpus spongiosum. In the older and 
more pronounced cases the corpus spongiosum is exten- 
sively infiltrated and of asemi-cartilaginous consistency; 



MORBID ANATOMY OF STRICTURE. IO^ 

so dense may it become that perfect erection is impos- 
sible. The condition under such circumstances is really 
one of chronic interstitial inflammation of the corpus 
spongiosum, which acts precisely like a localized acute 
inflammation of the same tissue, in that it gives rise to 
chordee. Bridles or bands, or flaps of thickened muc- 
ous membrane may be found in different cases. 

The degree of occlusion of the lumen of the canal 
is very variable. In' some cases of stricture of large 
calibre, superficial infiltration and thickening of the 
mucous membrane is localized to a very small spot in 
the urethra — perhaps not involving the entire cir- 
cumference of the canal — and its lumen is contracted 
but little if any. In the more severe forms, occlusion 
may be almost complete. 

The secondary results of stricture are chiefly incidental 
to the obstruction which it produces to the outflow of urine, 
and vary greatly hi degree. In extreme insta?ices, all the 
possible conditions incidental to urinary obstruction and 
chronic inflammation of the urinary way, have been found 
post-mortem. 

The urethra anterior to organic stricture may be 
somewhat contracted as a consequence of chronic in- 
flammation of the mucous membrane, associated with 
comparative disuse. The stream of urine which passes 
through the stricture not being of sufficient size to per- 
fectly dilate the anterior portion of the canal, contrac- 
tion might naturally be expected. It has been said 
that the urethra anterior to a stricture is in rare 
cases dilated, I cannot see, however, how this could 
occur, unless possibly as a result of extensive atrophy 
of the sub-mucous follicles and connective tissue. 

The obstruction to the flow of urine will necessarily 
first affect the urethra just posterior to the stricture. At 
the point the canal becomes more or less dilated, and in 
extreme cases thinned. As a consequence of interference 
with the wave of contraction of the accelerator urinae 



104 STRICTURE OF THE URETHRA. 

and compressor urethrae muscles produced by the plastic 
deposit constituting the stricture, in combination with 
the dilatation behind it, this part of the canal is never 
free from urine, a drop or so invariably remaining after 
the act of micturition; this residual urine, after the pro- 
cess is well advanced, decomposes and enhances the chro- 
nic inflammation already existing. The inflammation 
is still further enhanced by the friction of the urine, and 
in extreme cases by the straining efforts incidental to 
its expulsion. As a consequence of the inflammation 
there will be found at this point a muco-purulent secre- 
tion of pasty consistency. It is this secretion which con- 
stitutes the discharge in most cases of gleet incidental 
to stricture. As the urine passes over the part, the 
secretion, in combination with more or less desquamated 
epithelium, is rolled up in little thready filaments — trip- 
per faden — and may be seen floating about in the urine 
if a bottle of that fluid be held up to the light. There 
may be considerable congestion of the mucous mem- 
brane, so that the secretion is sometimes mingled with 
more or less blood. This, in my experience, is espe- 
cially apt to be the case in syphilitics. 

As a result of urinary decomposition, there is like- 
ly to be found behind a tight stricture of long standing, 
a deposition of more or less earthy material, perhaps 
in the form of a small calculus. A small calculus of 
renal or vesical origin may become lodged at this point. 
In a recent perineal section I found a calculus as large 
as a marrowfat pea behind a tortuous stricture. 

As the case advances the mucous membrane behind 
the obstruction becomes very thin and fragile, and perhap 
ulcerated, and bye and bye, as a consequence of a strain- 
ing effort during micturition, it gives way, and a drop or 
two of urine, mingled with the germ-laden decomposing 
secretions of the part, escapes into the peri-urethral cel- 
lular tissue. Abscess with inevitable fistula — or per- 
haps as a consequence of burrowing, a number of 



MORBID ANATOMY OF STRICTRUE. 



I05 



fistulae — and infiltration of urine with resultant slough- 
ing and death, are possible or even probable results. 
Wherever such fluid as is extruded under such circum- 
stances, comes in contact with cellular tissue, it inevit- 
ably destroys its vitality, with the results just men- 
tioned. It resembles in its destructive effects upon 
cellular tissue, the poison of erysipelas; it produces, in 
short, a septic cellulitis. 

The various glandular structures which open into 
the urethra posterior to organic stricture, are invaria- 
bly affected to a greater or less extent in marked cases, 
by the urinary obstruction and mucous inflammation. 
Thus the urethral follicles, prostatic glands, Cowper's 
ducts, and the ejaculatory ducts, become dilated, thick- 
ened and inflamed, 
as a consequence of 
frequent and strain- 
ing efforts at micturi- 
tion. Even in that 
portion of the canal 
anterior to the stric- 
ture, the various sin- 
uses and follicles will 
be found to be di- 
lated — sufficiently so 
in many cases to 
obstruct the passage 
of fine instruments. 
Dilatation of these 
follicles and ducts is 
due to their success- 
ive distension and 
v . .. tr , FIG ' 4 °* ,, . .. evacuation by inflam- 

Extreme Results of Organic Stricture of long standing, J 

showing contracted and hypertrophied bladder, dilated f/^t-iT nrnHnrfQ V\\f* 

ureters, dilated pelves, and degenerated cortices of the LKJL J F 1 UUULl3, x lxt 
kidneys. (After Keyes.) prOState is more Or 

less congested and enlarged, as a result of the frequent 
bruising to which it is subjected in spasmodic and 




io6 



STRICTURE OF THE URETHRA. 




difficult urination. It is possible that this condition of 
affairs, as seen in inflammation, congestion or neuralgia 

of the vesical neck — 
with or without stric- 
ture — is one of the 
causes of enlarged pros- 
tate in advanced life. 
The bladder is al- 
ways more or less af- 
fected, even in stric- 
tures of moderate de- 
gree. As a result of the 
continual obstruction to 
the expulsion of urine, 
the detrusor urinae mus- 
cles become hypertro- 
phied. As the obstruc- 
tion increases the viscus 
becomes dilated, and 
of its walls, 
of 

muscular fibres are deficient in quantity, become dilated 
and thinned, as a consequence of 
which condition sacculi are pro- 
duced. In these sacculi urine 
collects and decomposes, and as 
a result calculi may form. In 
some rare instances the bladder, 
instead of being dilated, is enor- 
mously thickened from intersti- 
tial cystitis, and contracted so 
that it will hold but a very small 
quantity of urine. 

The mucous membrane be- 
comes affected by chronic inflam- 
mation and assumes a character- fig 42. 

i^«-^ J„J r „ ~«. r>1^4-., "U,,^ I"* ;„ Hypertrophy and Contraction of 
IStiC dUSky Or Slaty hUC It IS the Bladder from Stricture. 



FIG. 4l. 



Showing the Results of Urinary Obstruction of pOTtlOnS 
Long Standing. (After Crosse.) 1 , . 

where the bundles 




MORBID ANATOMY OF STRICTURE. 



10; 



covered by muco-purulent secretions, mingled with 
sabulous material, and is usually greatly thickened, and 
perhaps rugose. Calculi may form in the bottom of 
the bladder, in the same manner as under other cir- 
cumstances involving urinary obstruction. 

Inflammation and dilatation of the ureters and the 

pelves of the kid- 
neys occur sooner 
or later in extreme 
cases. Pyelitis, 
with or without the 
formation of renal 
calculi, will be 
found to exist un- 
der such circum- 
stances. Pyone- 
phritic or peri-ne- 
phritic abscesses 
may occur. The 
secreting structure 
of the kidneys un- 
dergoes those 
changes, which are 
described under 
the omnibus term, 
— surgical kidney. 
One of the char- 
acteristic condi- 
tions observed in 
surgical kidney is 
an interstitial pro- 
liferation of con- 
fig. 43. nective tissue and 

Extreme Results of Organic Stricture ot Longstanding, a deficiency of the 
(After Morris.) t c -\ 

elements 01 the 
normal stroma Nature is very prodigal in her 
supply of reparative material to relieve strain, prevent 




IOS STRICTURE OF THE URETHRA. 

irritation or repair breaches of tissue. Obstruction to 
the urinary outflow, results in the accumulation of a 
physiological army of proliferating cells sent to the 
renal tissue or developed in loco, for the purpose of re- 
sisting a strain — which is interpreted by the trophic cen- 
ters as a threatened breach of tissue. Unfortunately, 
this tissue reinforcement, as it organizes, develops no 
qualities of elasticity, and as the strain goes on, itself 
yields and enhances the process of passive dilatation. 
Moreover, it not only absorbs almost as rapidly as it is 
formed — after a certain point has been reached— but 
it displaces, strangulates and produces absorption of, 
the normal secreting elements of the renal glands. 

In some of the more distinctive types of surgical 
kidney, associated with pyelitis, pyelo-nephritis or 
pyo-nephrosis, we find disseminated suppurative foci 
in the secretory structure, i. e. the cortex of the kidney. 
These foci may form in two ways, viz.: by direct in- 
fection — by contiguity of tissue — or by indirect infec- 
tion by pyaemic infarets as a part of a general pyo- 
genic septic infection. Whether this be due to pto- 
maines or to germs per se is not pertinent at this point. 

In fatal cases of uraemia, following operations for 
stricture, the secreting structure is usually found to be 
remarkably congested and swollen from reflex hyperae- 
mia, produced by the shock of operation. 

It is to be remembered that these various conse- 
quences of stricture, which have been enumerated, are 
not due to any specific quality of the lesion, but are the 
typical results of extreme and prolonged conditions of 
obstructive disease of the genito-urinary tract, no mat- 
ter what the cause may be. As far as stricture is con- 
cerned, we have possible pathological results suffi- 
ciently numerous and severe to convince the most 
skeptical, that through the medium of stricture, gonor- 
rhoea is indeed a serious disease. The results of stric- 
ture, and the operations necessary for its cure, are often 



PLATE IV 



e 




^zz^rX^^^^^^^^ 



After Dittel.) 



MORBID ANATOMY OF STRICTURE. IOg 

directly fatal to life. It is this fact that makes gonor- 
rhoea a much more dangerous disease than syphilis. 

The density of stricture necessarily varies consid- 
erably according to the duration of the case, its ori- 
gin, the habits of the patient, and the amount of 
irritation present. In old and pronounced cases it may 
be almost cartilaginous in consistency. Strictures of 
traumatic and chemical origin are very hard, from the 
simple fact that in them, a greater or less amount of 
the normal tissue has been completely destroyed and 
replaced by true cicatricial tissue. 



CHAPTER VII. 



CAUSES, SYMPTOMS, DIAGNOSIS AND 
PROGNOSIS OF STRICTURE. 

The most frequent cause of stricture is urethritis, and 
it has been said that it is the duration rather than the 
severity of the inflammation which determines its oc- 
currence ; in other words, that a long continued inflam- 
mation of a low grade is the most usual cause. This, 
however, is open to question, for, while stricture results 
many times from chronic urethritis, it must be acknowl- 
edged that in the majority of instances the symptoms 
of chronic inflammation are dependent upon the stric- 
ture, and the stricture itself upon antecedent virulent 
inflammation — in brief, it is the stricture that causes a 
perpetuation of the inflammation and not the reverse. 
It may be rank heresy, but I believe that it may be 
safely assumed that the danger of subsequent stricture ', and 
of chronicity hi urethritis, is directly proportionate to 
the severity of the acttte inflammatory process. Re- 
peated attacks of inflammation almost inevitably 
lead sooner or later to organic stricture. It is rather 
exceptional — if indeed it occurs at all — that the 
urethra assumes its normal condition throughout its 
extent, for a long time after a virulent urethritis, 
as there exists in most instances, one or more dam- 
aged spots in the mucous membrane. In quite a pro- 
portion of instances these spots will sooner or later 
form a foundation for stricture; but they will inevit- 
ably do so, and in a comparatively short time, if the 
individual contracts a succession of attacks of gonor-. 
rhcea. 



CAUSES OF STRICTURE. Ill 

Stricture may result from traumatism produced by 
instruments within the canal or by injury from without. 
Severe injuries to the perineum usually involve the 
urethra. When they do so, they are inevitably followed^ 
as already indicated, by the worst form of organic 
stricture. When the urethra is entirely cut across, or 
severely bruised, the loss of tissue is invariably re- 
placed, as in other situations, by extensive cicatricial 
deposit. Indeed it is disproportionately dense, on ac- 
count of the lack of rest incidental to urination and 
sexual excitement. This tissue contracts and consti- 
tutes a stricture. Injuries which were apparently 
trivial at the time, and have perhaps been long forgot- 
ten, are not infrequently the source of strictures the 
occurrence of which cannot be otherwise explained. It 
takes but little force to injure the deep urethra, and an 
accident which has produced apparently little or no 
injury is liable to affect the urethra sufficiently to de- 
velop stricture later on. 

Injury to the perineal urethra may result from 
kicks, blows, and falls astride such objects as a wall or 
a fence. I have seen one case occurring in an athlete, 
as a consequence of falling astride a horizontal bar. 
Fracture of the pelvic bones has been known to pro- 
duce traumatic stricture. Gunshot or stab wounds may 
produce it. 

The forcible rupture of chordee superadds trau- 
matism to the usual inflammatory causes of stricture. 
Careless instrumentation is often responsible for the oc- 
currence of stricture. It is a very easy thing to force 
a catheter or sound through the urethral walls, or to 
produce sufficient injury by bruising and laceration to 
result in cicatricial deposit and consequent stricture. 

Cicatrices from chancre and chancroid, occurring at 
the meatus or within the urethra, may produce stric- 
ture. 



112 STRICTURE OF THE URETHRA. 

Urethral injections are popularly supposed to be 
responsible for a large proportion of cases of stricture, 
and this, it must be confessed, has some foundation in 
fact, for some surgeons, in their enthusiasm and desire 
for a speedy cure of their cases, are apt to forget that 
the urethra is lined by a very delicate mucous mem- 
brane, which is normally extremely sensitive to irri- 
tants, and is certainly more sensitive than ever when 
it is inflamed. Injections of a mild character, given in a 
proper manner, and at the proper period, will not produce 
stricture, but on the contrary, will tend to prevent it by 
their beneficial effect upon the inflamed membrane. 
The prejudice which usually exists in the minds of the 
laity regarding the use of injections is to be deplored, 
as the method is often a very useful one. Although the 
surgeon may sometimes be responsible for the occur- 
rence of stricture, it is safe to say that in the majority 
of instances the disease is due to aggravation of the in- 
flammation by a lack of rest, sexual indulgence or 
excitement, intemperance and self-treatment. The 
counter-prescribing in vogue among a certain class of 
druggists is often responsible for stricture. This is a 
matter which physicians would do well to take under 
advisement. There is no disease with which the coun- 
ter-prescriber takes as many liberties as with gonor- 
rhoea. The results are oftentimes very disastrous to 
the patient. 

Independently of the strength of injections, it is to 
be remembered that the blandest of fluids may, when a 
urethritis is very acute, produce irritation by their 
mechanical action alone. 

It is probable that individual peculiarities exist in 
some instances as predisposing causes of stricture. 
Thompson believes that heredity is a factor in its forma- 
tion in some instances. His remarks upon the subject 
are as follows: 

" In exceptional cases, from a constitutional indis- 



SYMPTOMS OF STRICTURE. 113 

position to terminate inflammatory action, this latter 
persists and produces a deposit which ends in stricture. 
This cause is not a speculative theory, for I am now sat- 
isfied that in certain families, individuals inherit a pro- 
clivity to the formation of stricture."* 

The theory that individuals in some families, pre- 
sent a marked tendency to connective tissue and fibrous 
thickenings in various situations, as a result of chronic 
inflammation, is a plausible one, yet it would be diffi- 
cult in the majority of cases to trace the relation of 
heredity to stricture, and in any event the question is 
hardly a practical one. 

Cachexias of various kinds certainly act as predis- 
posing causes of stricture, in so far as they tend to per- 
petuate and enhance the severity of inflammation, in 
whatever situation it may arise. I think it will be found 
that individuals with a syphilitic constitution are rela- 
tively more apt to develop stricture as a result of gon- 
orrhoea, than other individuals. This is probably be- 
cause a localized proliferation of syphilized cells is apt 
to occur at any point of local irritation which develops 
during the active course of syphilis. This is a practical 
point, as it is obvious that in such cases internal medi- 
cation may be a very useful adjunct to strictly surgical 
measures. The same considerations apply to the exist- 
ence of thegouty and rheumaticdiatheses. Any condition 
which favors hyper-acidity of the urine, predisposes to 
stricture. Patients who are habitual drinkers are rela- 
tively more apt to develop stricture than are total 
abstainers. The constant ingestion of alcohol makes 
the tissues in general, irritable and prone to inflamma- 
tion, both acute and chronic. 

SYMPTOMS OF STRICTURE. 

One of the earliest symptoms of stricture of the 
urethra is disturbance of the function of urination. 

"Thompson. Op. Cit. 



114 STRICTURE OF THE URETHRA. 

The decomposition of the small quantity of urine which 
collects behind the. obstruction after the process has 
become moderately advanced, gives rise to organic com- 
pounds which are very irritating to the mucous mem- 
brane — as is evidenced .by the chronic inflammation 
found at this point. This condition causes reflex or di- 
rect irritation of the neck of the bladder, with a result- 
ing frequent desire to urinate. Some patients will first 
consult the surgeon regarding an increased frequency 
of micturition, possibly occurring only at night. Under 
normal circumstances the bladder will tolerate its con- 
tents during the hours of sleep, but in the presence of 
irritating affections of the genito urinary tract, it be- 
comes intolerant of the urine and must therefore be fre- 
quently evacuated. It is not unusual to meet with 
patients who have been annoyed by several calls to 
urinate during the night for a number of years, but 
who have never been troubled in any other way by 
their stricture — which is, as a rule in such cases, of 
large calibre. Oftentimes such patients have a stric- 
ture at the meatus only. A stricture at the meatus 

may give rise to frequent" urination by producing re- 
flex irritation of the neck of the bladder, the rest of the 

urethra being free from disease. 

A very frequent early symptom of stricture consists in 
dribbling of urine after micturition, when the patient 
supposes that he has thoroughly cleared the urethra of 
fluid. This is due to interference with the continuous 
wave of contraction of the accelerator urinse and com- 
pressor urethrae muscles, the function of which is to ex- 
pel the last few drops of urine or semen from the canal^ 
As soon as the penis is allowed to hang downwards, 
the residual urine, or rather a portion of it, escapes and 
soils the clothing of the individual. It is not unusual, 
even in cases of stricture of quite large calibre, for im- 
perfect ejaculation of semen to occur, with a similar 
dribbling of the fluid after the penis becomes flaccid. 



SYMPTOMS OF STRICTURE. I 1 5 

This, I think, is chiefly due to reflex inhibition of the 
function of the urethral muscles. 

The stream of urine may be forked, or twisted into 
a corkscrew fashion, according to the form of the stric- 
ture. In some instances, a straight stream will be pro- 
jected from the meatus, while a second stream falls 
perpendicularly downwards. The size and form of 
the meatus modifies to a considerable extent the form 
of the stream, for in cases of stricture of large calibre, 
the meatus, if narrow, may counteract the effect of the 
obstruction and maintain the natural form of the 
stream. When the meatus is large and its lips turgid, 
the stream may present a fan shape, or there may be 
several streams running in different directions, very 
much after the fashion of the stream of water thrown 
from a garden sprinkler. This occurs in some persons 
who are free from stricture. 

A little later on in the case the patient finds that 
more or less effort is required during the act of mic- 
turition, the abdominal muscles being unconsciously 
brought into play to supplement the action of the de- 
trusor urinae. As this condition of affairs goes on, 
more or less atony of the detrusor occurs, and a stiil 
greater effort is required to empty the bladder. So 
severe does the strain become in pronounced cases, 
that haemorrhoids, prolapse of the rectum and marked 
turgescence of the prostate may occur. 

After a time, as the case progresses, the stream 
of urine becomes extremely small, perhaps escaping a 
few drops at a time, and necessitating the devotion of 
considerable time to the act of urination. Ejaculation of 
semen may now be so interfered with that the fluid, 
instead of escaping into the vagina as under ordinary 
circumstances, is forced backwards, overcoming the 
resistance of the vera montanum, and passing into the 
bladder. If this condition of affairs lasts for a long time 
the function of the veru montanum may be inhibited 



Il6 STRICTURE OF THE URETHRA. 

completely and permanently, so that the individual 
ever afterwards ejaculates the greater portion of the 
seminal discharge into his own bladder. Very often 
little or no semen will be discharged during the orgasm, 
for the reason that the increased turgescence of the 
corpus spongiosum, in conjunction with obstruction pro- 
duced by the stricture, is sufficient to completely oc- 
clude the urethra during erection. The semen under 
such circumstances, instead of passing backwards into 
the bladder, may remain in the urethra to dribble away 
as soon as the organ becomes flaccid. Under such cir- 
cumstances sterility is an inevitable consequence. 
Partial or complete impotency may result from stric- 
ture as a consequence of the local and reflex ennervat- 
ing influenceof the disease. In many instances the ir- 
ritation of the stricture produces obstinate priapism 
and excessive desire. 

Neuroses from stricture: While the majority of cases 
of stricture are unattended by pain of any kind, there 
is in quite a proportion of instances both direct and 
reflex symptoms of a painful character. Neuralgic 
pains in the groins or shooting up and down the sper- 
matic cord, the front of the thighs and in the lumbar 
region are not unusual. Neuralgic pains in remote 
situations are occasionally experienced. I have met 
with numerous cases of this kind. One of my cases in 
particular was very interesting, in that an obstinately re- 
curing angina pectoris was apparently cured by a 
urethrotomy for an irritable stricture. 

The remote or direct nervous disturbances inciden- 
tal to stricture of the urethra, are too often lost sight 
of in the strictly mechanical aspect of the condition. 
The decidedly complex relations of the genito-urinary 
apparatus to the sympathetic nervous system, should 
receive more attention than is usually accorded them. 
Our observations of the reflex neuroses from genital ir- 
ritation in children, are a key to the solution of many 



NEUROSES FROM STRICTURE. 1 17 

problems in the urethral pathology of the adult. There 
is a general impression that a stricture is of little im- 
portance unless it produces distinct symptoms of urin- 
ary obstruction. When, however, one meets with cases 
of vesical atony, incontinence of urine, impotency, 
neuralgia of the cord and testes, lumbo-hypogastric and 
lumbo-sacral neuralgia, profound mental depression and 
other neuroses, entirely and almost magically relieved 
by urethrotomy of strictures of large calibre, the im- 
portance of this question is brought before him in a 
very forcible manner. The relation of such conditions 
to congenital or acquired stricture at or near the meatus, 
is especially marked. 

General malnutrition, hypochondria and malaise 
are often complained of in stricture. Nervous irrita- 
bility is often a prominent feature of the case. Local 
pain referred to the neck of the bladder, rectum, perin- 
eum and hypogastrium are often experienced. 

As the morbid tissue of the stricture increases in 
amount and density, it becomes more irritable, and at- 
tacks of complete retention of urine are apt to occur as 
a consequence of spasm of the urethral and cut-off mus- 
cles, with or without congestion or inflammation at the 
site of the stricture. There may be in such cases 
acute cystitis as a complication. The plus conditions 
which cause retention of urine are usually superinduced 
by sexual excesses, intemperance or exposure to wet 
and cold, often in combination with the dietetic ex- 
cesses. Gouty and rheumatic patients are especially 
liable to retention. As a consequence of retention rup- 
ture of the urethra behind the stricture, or even rup- 
ture of the bladder may occur, the urethra being how- 
ever, most apt to give way. 

Following an attack of retention, acute cystitis may 
develop. The danger of this complication, however, de- 
pends to a great extent upon the degree of care exer- 



Il8 STRICTURE OF THE URETHRA. 

cised by the surgeon in relieving the distended bladder. 
Infection and traumatism are very easily produced. 

Toxcemia from Stricture. — The relations of stric- 
ture to uraemia — so-called — is not a new theme. 
Something will be said later on regarding the relation 
of the shock from surgical operations upon the urethra 
to toxaemia and consequent urethral fever; the sub- 
ject is too comprehensive for discussion at this point. 

The relation of absorption of ptomaines from the site 
of the lesion in stricture — or from behind it — to the gen- 
eral results of stricture, is unquestionably of great im- 
portance. The rapidity with which many constitutional 
symptoms disappear after cure of deep strictures, is 
thus easily explained. Urethral chill following instru- 
mentation is also explicable in the same way in some 
cases. 

The possibility of mixed infection must be taken 
into consideration. The cases of cystitis, epididymitis, 
peri-urethral phlegmon, pyelo-nephritisand other spec- 
ial phenomena secondary to stricture, are not all 
dependent upon direct extension of inflammation, but 
are probably due in many cases to secondary infection. 
A recent case of my own is strongly suggestive in this 
regard. A patient whom I was treating by dilatation for 
several irritable strictures of comparatively large calibre, 
veloped multiple nephritic and perinephritic abscesses 
during the course of treatmeni. An interesting point 
was the fact, that the formation of the abscesses was 
heralded by great increase of irritability and spasm in 
the deep urethra. 

The point which I desire to urge most strongly is 
the apparent fact that all patients with serious stric- 
tures — particularly of the deep urethra — suffer from a 
greater or less degree of toxaemia, and that many 
cases develop secondary single or multiple infections of 
one kind or another. 



THE DIAGNOSIS OF ORGANIC STRICTURE. 1 19 

That the passage of instruments may precipitate 
toxaemia is granted. The danger is enhanced by un- 
cleanliness, but strictly aseptic instruments may cause 
trouble. It is a question however, whether any instru- 
ment passed through a diseased anterior urethra can be 
aseptic by the time it reaches the deeper portions of 
the canal. It is my firm conviction that strictly aseptic 
surgery of the urethra would demand a flushing out of 
the canal prior to the introduction of even an ordinary 
sound. This, we know, is not ordinarily done, nor is 
it always practicable. We are most of us, therefore, 
committing cardinal sins from the standpoint of aseptic 
surgery as a matter of routine. 

The various complications and sequelae of stricture 
produce special and characteristic modifications of the 
symptomatology and course of the disease. Thus there 
may occur a special set of symptoms dependent upon 
prostatic inflammation and abscess, vesical and perivesi- 
cal inflammation, urethral rupture with infiltration of 
urine, and the various renal complications which so fre- 
quently occur in the course of stricture. 

THE DIAGNOSIS OF ORGANIC STRICTURE. 

The diagnosis of organic stricture can only be made 
by instrumental exploration of the canal. The facility 
of examination depends upon the condition of the 
meatus to a great extent. It is obvious that with ordi- 
nary instruments a thorough exploration cannot be 
made through a narrow meatus. For example, if the 
canal be very large, its extreme capacity being 45 
French, and stricture exists at different points, the 
canal being contracted at one or more of them to a 
diameter of 30 French, the condition cannot be readily 
detected through a meatus of a calibre of 20. Dr. 
Otis has devised an instrument, which has become very 
familiar to American surgeons, for the purpose of over- 
coming the obstacle afforded by a narrow meatus. This 



120 



STRICTURE OF THE URETHRA. 




instrument — the urethrameter — consists of a series of 
blades, operated by a thumb-screw, and connected with 
a scale-plate or dial, with an indicator which shows the 
exact degree of expansion of the blades as represented 
by the French scale, when separated at different points 
in the course of the canal. This instru- 
ment is especially useful when an accurate 
record of cases is to be kept. 

With the soft bulbous bougie, it is possi- 
ble to accomplish almost as much from a 
practical standpoint as with the urethra- 
meter. After a preliminary meatotomy the 
canal may be explored with a series of such 
bougies about as accurately, and perhaps on 
the average more intelligently and safely, 
than with the urethrameter. Incision of the 
meatus is devoid of danger if properly done, 
and is almost invariably beneficial in cases 
in which symptoms of genito-urinary irrita- 
tion exist, whether stricture be present or not. 
I have, however, seen one case in the practice 
of another surgeon in which considrable 
sloughing followed meatotomy. This was un- 
questionably due to instrumental sepsis. The 
danger of injury by the urethrameter may 
be obviated to a great extent, by covering 
the end of the instrument with a thin 
sheath of rubber; this does not usually inter- 
fere with the separation of the blades, but 
does prevent the falling of the mucous 
membrane between them. With some pat- 
terns of the urethrameter and when the rub- 
ber sheath is thick, the blades of the instru- 
ment are apt to twist, corkscrew fashion, 
as they are opened.* A valid objection to 
the urethrameter, is that by its use, strictures of large 

*The urethrameters of more recent construction have stouter blades which are jointed 
at the center of their convexities: This is a great improvement. 




fig. 44. 

Otis' Improved 
Urethrameter. 



THE DIAGNOSIS OF ORGANIC STRICTURE. 



121 



calibre can be found in every urethra at points of 
normal contraction. Some nicety of judgment is 
therefore necessary in estimating the points of nar- 
rowing demonstrated by the ureth- 
rameter at their true value. I believe 
that in quite a large proportion of 
healthy urethrae strictures may be de- 
tected with the urethrameter if Dr. 






FIG. 45. 

Bulbous Bougie at a Stricture. (Culver-Harden.) 



Otis' mothod of examination is too 
arbitrarily followed. This objection 
of course falls to the ground in 
cases in which there is a more or 
less definite relation between the 
points o-f narrowing and existing 
pathological conditions. In such cases 
it makes little or no difference 
whether the points of narrowing 
were once physiological or not; they 
have assumed pathological impor- 
tance even though they be not of pathological origin. 

Meatotomy should be considered a necessary prelimi- 
nary in both the diagnosis and treatment of urethral dis- 
ease in any case in which the meatus is not of sufficient calibre 
to admit an instrument measuring from 30 Fr, upwards. 
Some latitude, however, must be allowed, the size of 



4 4 4 

FIG. 46. 

Otis' Bulb Sounds, 



122 STRICTURE OF THE URETHRA. 

the penis being taken into especial consideration. Dr. 
Otis adopts as his criterion of the normal size of the 
canal the circumferential measurement of the penis in 
its flaccid condition, believing that there is a constant 
relation between the size of this organ the calibre of 
the urethra. This is probably true within certain limits, 
but the size of the organ is so variable at different times 
that it seems to me hardly safe to adopt this as an arbi- 
trary rule. The mental effects of simple sounding often 
cause the penis to shrink to very small dimensions. I have 
had patients who claimed that the very idea of exposing 
the organ, was sufficient to produce this temporary shriv- 



^=\ 








/? 




^=s; , 


i . ii \ 


! ■" 12 , 1 , la , 1 . 14. , .1" 


_i_ '& , 


i , &. 


-^ 






Truax. Greene & Co. 









FIG. 47. 
Weiss' Bougie a Boule. (Ruled Staff.) 



fig. 43. 
Guyon's Bougie a Boule. 



elling. In incising the meatus, due deference should be 
paid to its form. When the orifice is situated low down 
upon the extremity of the glans, it cannot be incised so 
widely as when it is located higher up, and as arule it will 
be found that the lower its situation, the more distensible 
it is apt to be, and the less frequently does;it require in- 
cision. Whenpracticable, the orifice should be cut larger 
than the size which it is desirable for it to retain per- 
manently, as some cicatricial contraction is inevitable. 
Dr. Otis' scale showing the normal size of the urethra 
is practically as follows: A penis measuring 3 inches 
in circumference should have a urethra of a calibre of 
30. Fr. For each % inch of circumference 2 m. m. 
is added to the calibre of the urethra; — thus 3^ in.— 32 
Fr., y/ 2 in. = 34 Fr., 3^ = 36 Fr., 4 in. = 3 8Fr., 4% in. 
and over, = 40 Fr. 



MEATOTOMY 



123 



Several instruments have been devised for meato- 
tomy, the most familiar being the bistouri cache of Civiale. 




Fig. 49. Piffard's Meatometer. 

This instrument is composed of two blades, one cutting 
and the other blunt, separableby means of ascrew. Hav- 



Truax, Gree ne & Co- 




Fig. 50. Civiale's Meatatome {Bistouri Cache.) 

ing been introduced for a sufficient distance within the 
meatus, the blades are separated to the required extent 
and the instrument is withdrawn, incising on the way 
the inferior commissure of the meatus. With this in- 
strument more cutting is apt to be done than is intended, 
and it is to say the least, a bunglesome device for the 
performance of a very simple operation. A straight 
backed, probe pointed, narrow bistoury, such as that of 
Dr. Piffard, is the best instrument for this purpose, and 
in expert hands an ordinary scapel will do in lieu of a 
special instrument; the scapel maybe used in combina- 
tion with a director, or its point may be covered with a 
bit of wax, thus preventing accidental injury to the 
canal. The incision should be made directly down- 




Fig. 51. PiffarcTs Metotome. 



wards, care being taken not to cut through the Moor of 
the urethra. Under cocaine the operation may be made 
perfectly painless. A 4 per cent, solution in water or an 
8 per cent, oleate, may be injected into the canal by 



124 STRICTURE OF THE URETHRA. 

means of a drop syringe, and retained for about five 
minutes, at the end of which time the part will usu- 
ally be well anaesthetized. The haemorrhage following 
meatotomy is sometimes considerable. I have exper- 
ienced more trouble in this respect since using cocaine 
than formerly. The drug not only produces local anaes- 
thesia, but also appears to produce vaso-motor paresis 
and venous congestion; the escaping blood will be found 
to be dark and of a more venous hue than under ordi- 
nary circumstances. Severe bleeding is not usual, how- 
ever, at the time of the operation, as the drug seems to 
act primarily to a certain degree as an astringent. The 
next act of urination, however, after the astringent 
effect of the drug has passed off, is apt to be attended 
by considerable bleeding. If oozing is obstinate at the 
time of operation much time may be saved by plugging 
the meatus; for this purpose I use a wedge shaped piece 
of dentist's spunk. This is prepared by saturating it in 
a solution of bichloride of mercury, 1-500, and drying. 
This substance swells somewhat when it is wet and plugs 
the meatus sufficiently to check the bleeding. Should 
it escape at the next act of urination, as it is apt to do, 
the patient should be instructed to pinch the under sur- 
face of the glans at the site of the incision, with the 
thumb and finger, until the bleeding is arrested. Dan- 
gerous loss of blood cannot occur if this be done, and 
the pressure will usually check the haemorrhage within 
a few moments. If the patientbe nervous and excitable, 
he may become frightened by the occurrence of haemor- 
rhage, and losing his presence of mind, may not apply 
the pressure properly, as a consequence of which consid- 
erable loss of blood results. An instance of this kind oc- 
curred in my own practice, in which sufficient blood was 
lost to induce syncope. In this case I was obliged to in- 
troduce a small sponge-tent, before I could finally check 
the bleeding. Aside from the trifling danger of haem- 
orrhage of this character, I have never seen any unto- 



MEATOTOMY. 1 25 

ward results from meatotomy, excepting in the instance 
already mentioned in which a patient operated upon by 
one of my friends, suffered from sloughing of a portion 
of the glans about the incision. Such accidents may 
be avoided by strict asepsis. The meatus should be 
dilated every day or two with a full sized sound, for 
about two weeks, to prevent its growing together. 
Stitching of the edges of the quasi-mucous covering of 
the glans and the mucous lining of the urethra together, 
has been suggested for the purpose of insuring the pa- 
tency of the meatus, and is often of value. I have fre- 
quently practiced this with advantage. This is not 
usually necessary, however, if proper attention be paid 
to dilatation during the process of healing. 

If meatotomy is a preliminary to treatment by dila- 
tation, it is well to waituntil the incision has healed before 
treating the deeper parts of the urethra. Exploration 
or internal urethrotomy may, however, be completed at 
the same operation. When the patient cannot visit the 
surgeon frequently, a loop of wire or a hair pin may be 
bent to the required size and passed into the meatus 
several times daily for the purpose of keeping it open. 
Careful stitching of the cut edges is also of service 
under these circumstances. 

Dr. Keyes states that dilatation after meatotomy is 
not necessary, even going so far as to say that: "A 
meatus properly cut remains open indefinitely, without 
the necessity of dilatation."* I do not know what this 
distinguished surgeon means by the term ''properly cut" 
as I am not aware that he has any special method of 
operation, and moreover, I have found that in almost 
every instance when the meatus has been incised in the 
manner which I have considered proper and have al- 
ready outlined, the cut surfaces have almost invariably 
found to be adherent upon the following day. In fact, 
un : on by first intention often occurs, and mere separa- 

♦Revision of Van Buren and Keycs, p. i?4- 



126 STRICTURE OF THE URETHRA. 

tion of the adherent lips of the wound is sufficient to 
cause quite free haemorrhage. 

In some cases the fraenum preputii is attached so 
far foward that a proper meatotomy cannot be per- 
formed. In such cases the fraenum should be cut away 
in such a manner as to leave a clear field for the inci- 
sion of the meatus. 

Regarding the possible injury which has been igno- 
rantly alleged to result from meatotomy, I will take oc- 
casion to say at this juncture, that meatotomy, properly 
performed, is never productive of untoward results. I 
am thus emphatic because the fine ethical sense of sev- 
eral of my professional brethren has impelled them 
to remark to patients upon whom I had performed the 
operation, that it was an injury to the organ. Whether 
pitiful ignorance or a less admirable quality actuates 
such men is of little consequence, — their statements are 
absolutely false Experiences of this kind are con- 
stantly occuring in the career of the conscientious sur- 
geon, and he is fortunate if he can regard them philo- 
sophically. 

Aside from the mere fact of the existence of obstruc- 
tion hi the course of the canal, there are several other points 
zvhich may be determined by expert exploration; this implies 
exploration by the urethrameter or bulbs, the ordinary 
sound being rela lively worthless. 

i. — It is obvious that the degree of contraction or 
calibre of the stricture is quite readily determined 

2. — By careful measurements the distanceof thestric- 
ture from the meatus can be quite accurately estimated. 

3. — If the bulbous bougie or urethrameter be passed 
beyond the stricture and then withdrawn until it is 
caught, the distance of the posterior surface of the ob- 
struction from the meatus may be determined 

4. — The space included between the two measur- 
ments corresponds very nearly to the width of the stric- 
ture. 



THE DIAGNOSIS OF ORGANIC STRICTURE. 1 27 

5. — The number of strictures is determined with 
only moderate facility with the bulbs, for the reason 
that the obstruction in the anterior portion of the canal 
may be sufficiently small to prevent the introduction 
of an instrument large enough to impinge upon the deeper 
strictures. This does not apply to the urethrameter, 
except in very tight strictures of the pendulous portion. 

6. — The condition of the urethra behind the stric- 
ture may be approximately determined by examining 
the secretion withdrawn from the canal by the sholder 
of the instrument. When this is thick, with a prepon- 
derance of purulent qualities, and containing sabulous 
material, a relatively pronounced degree of chronic in- 
flammation may be inferred to be present. When there 
is little or no secretion, or when such as is present is of 
a mucoid character, the stricture may be inferred to 
be in a moderately passive condition, and the urethra 
behind it to be comparatively healthy. 

7. — The amount of congestion present at the site of 
stricture may sometimes be estimated. When blood 
appears upon the shoulder of the instrument, or escapes 
from the urethra after its withdrawal— the exploration 
having been conducted with gentleness — a considerable 
degree of congestion at the site of the stricture is evi- 
dently present, 

8.— Resiliency or irritability of the stricture may be 
determined. Resiliency or elasticity of the stricture is 
shown by the ready passage of a comparatively large 
sound, whereas the bulb of a much smaller bougie is ob- 
structed. Irritability is demonstrated by the pain and 
spasm excited by the exploration and the subsequent oc- 
currence of urethral chill. 

After the exploration of the urethra for the first 
time, ten grains of quinia in combination with one-quar- 
ter of a grain of morphia should be administered to ob- 
viate a possible chill and urethral fever. Dr. Keyes 



128 STRICTURE OF THE URETHRA. 

advocates the use of diuretin in meeting this indication.* 
Should the patient be very sensitive or the stricture a 
severe one, it may be well to administer a drachm of 
the fluid extract of jabarandi or a hypodermic of % to 
Yi of a grain of pilocarpine. On account of their deriv- 
ative and eliminant effects these drugs are very use- 
ful, particularly in cases in which uraemia is to be appre- 
hended on account of the existence of marked renal 
disease. 

The patient should be advised of the probability of 
severe smarting and perhaps pain at the next act of 
micturition, and also of the possibility of an increase of 
urethral discharge, or its appearance if it does not al- 
ready exist. Alkaline diluents, the balsams, and — if the 
stricture be severe with complicating cystitis — boric 
acid should be administered. No further meddling is 
admissible for several days after the exploration. 
Should urethral discharge be free, however, mild bi- 
chloride injections are admissible. 

PROGNOSIS OF STRICTURE, 

The prognosis of stricture involves two consider- 
ations : (i) Its culpability % and (2) its danger to life. 

The possibility of a radical cure for stricture is dis- 
puted by the majority of surgeons; indeed the general 
opinion up to a recent date has been to the effect that 
without continual attention, a stricture once formed, 
will sooner or later give the patient trouble, no matter 
how skillfully, or indeed how successfully, his case may 
appear to have been treated. For example, it has been 
supposed that, as a rule, an individual who has been 
apparently cured of stricture during early adult life will 
again be troubled by the disease as he approaches mid- 
dle age, unless he has in the meantime carried out more 
or less perfectly, treatment by dilatation — the necessity 
for which increases with advancing age. Were it not 

*E. L. Keyes. Op. Cit. 



PROGNOSIS OF STRICTURE. 1 29 

for the labors of Dr. Otis and his disciples, this old-time 
belief would probably never have been disputed, but 
through the labors of these investigators it lias been shown 
that quite a proportion of radical cures of stricture may be 
attained by the Otis ope7'ation of dilating urethrotomy > al- 
ways providing suck strictures are located in the pendulous 
portion of the urethra. No system of treatment that has 
yet been devised has been conclusively shown to produce 
a permanent cure of stricture of the fixed urethra, with 
the possible exception of a few cases of perineal sec- 
tion It has been held to be questionable in some quar- 
ters whether even those strictures which occur in the 
penile portion of the canal have ever been radically 
cured, but as many cases which have been operated 
upon by the Otis method have been examined upwards 
of 15 years after operation, and have been found to re- 
main perfectly free from a recurrence of the trouble, as 
is shown by careful urethrametry, it. is fair to assume 
that in such cases a radical cure has resulted. I base this 
opinion not alone upon the claims of Otis and his school, 
but upon thirteen years experience with the opera- 
tion and a number of cases reaching well up into the hun- 
dreds. This point will be expatiated upon in the dis- 
cussion of urethrotomy. I do not think that in the in- 
stances of apparent cure by various methods in cases in 
which the disease recurs sooner or later, the canal if 
examined, would be found to be free from obstruction 
for any great length of time during the interim. If re- 
contraction occurs after complete dilatation, rupture or 
division of a stricture, such recurrence is probably dis- 
coverable by thorough exploration within a very short 
time after the cessation of treatment. Indeed, I think 
it will be found on careful exploration that re-contrac- 
tion, if it occurs at all, has usually begtin within the first 
year following an apparent cure. For example, an indi- 
vidual who at the age of 40 presents evidences of re- 
contraction of a stricture which was apparently cured 



I3O STRICTURE OF THE URETHRA. 

some years before, if examined during the interim, 
would have been found to have a certain degree of nar- 
rowing of the canal, if thoroughly explored by the bul- 
bousbougie or urethrameter. There are very few cases in 
deed in which re-contraction does not commence with- 
in six months after cessation of treatment; but this 
re-contraction, may progress very slowly or come 
to a standstill until some years have elapsed. At 
any time during this period however, marked and rapid 
re-contraction may occur as a consequence of acute or 
subacute inflammation excited by intemperance or sex- 
ual excesses. A recurrence of stricture occurs much 
more readily in cachetic, strumous, gouty, rheumatic 
and syphilitic patients than in those of a perfectly 
healthy constiution. Necessarily the habits of the patient 
have much to do with his prospects of immunity from a 
recurrence of the disease. 

It may be formulated as a practical rule, (1) that 
traumatic or chemical strictures invariably recur, no 
matter what form of treatment may be instituted. (2) 
That chronic inflammatory strictures of the deep ure- 
thra recur sooner or later, and if the urethra be care- 
fully explored they will be found to have re-contracted to 
a greater or less extent, within a comparatively short 
time after the cessation of treatment. (3) That stric- 
tures of the penile urethra rarely disappear completely 
under dilatation, and always recur, unless operated upon 
by urethrotomy; they rarely, however, recur — in the 
absence of fresh gonorrhceal infection — when operated 
upon according to the Otis method, if the operation be 
properly performed. 

It is usually possible to prevent re-contraction of 
a simple stricture if we can obtain the co-operation 
of the patient. Strict adherence to the principles of 
genito-urinary hygiene, and occasional dilatation of the 
urethra by means of a moderately large steel sound 
will generally prevent re-contraction, at least to a degree 



PROGNOSIS OF STRICTURE. I3I 

appreciable to the patient. When the patient is able 
to secure the services of a surgeon, it is unnecessary for 
him to be instructed in the art of self-instrumentation; 
under other circumstances however, he should be 
taught the use of the sound and instructed to introduce 
the instrument at first once a week, later on once in two 
weeks, and finally once a month. When once an indi- 
vidual has suffered from organic stricture the introduc- 
tion of the sound becomes an important item in his toi- 
lette. An English surgeon once remarked that the sound 
was one of the most important articles of the baggage 
of a traveling English gentleman. Judging by the fre- 
quency of stricture among our American population, 
the English nobility have no monopoly in this respect. 
The prognosis of stricture as regards its danger to life, 
varies greatly according to the duration of the disease, 
the severity of its complicating conditions and sequelae, 
and the character of the operations which are under- 
taken for its cure. Probably the most important factor 
in determining the prognosis is the condition of the kidneys'. 
The renal structure and function are almost invariably 
impaired — in fact, in organic stricture of long standing 
such impairment is to be inferred. Pathological aber- 
rations of the kidney are not only immediately danger- 
ous to life — either through acute exacerbations of in- 
flammation induced by intemperance or exposure, or by 
reflex inhibition of the function of the kidney produced 
by surgical shock in attempts at the cure of the stric- 
ture — but they bear an important relation to the future 
welfare of the patient, after the primary condition has 
been relieved. It is probable that a patient who has 
once suffered from secondary disturbances of the kid- 
ney, incidental to organic stricture, is rarely, if ever, 
a sound man again. His kidneys — and for that matter, 
the structures composing his entire genito-urinary 
tract — are in a weakened, possibly degenerated, relaxed 
and irritable condition which predisposes to conges- 



132 STRICTURE OF THE URETHRA. 

tion and inflammation. The slightest excess or expo- 
sure in such individuals is apt to bring on acute Bright's 
disease of theordinary form. Chronic nephritis is liable 
to supervene at any time. Pyelitis may develop after 
the patient is apparently cured of his stricture. In brief, 
it may be said that a patient who has once suffered 
from severe organic stricture possesses ever afterward 
a locus minoris resistentice in the direction of the kidneys, 
which is apt at any time to lead to pronounced renal 
disease,with perhaps a fatal result. 

Stricture may result fatally by the supervention of 
uraemia, consequent upon complete inhibition of the al- 
ready impaired function of the kidneys. Retention of 
urine, due to inflammation of the stricture, may lead to 
a fatal result through rupture of the urethra or bladder 
with consequent extravasation of urine, or by occurence 
of acute cystitis, — perhaps with gangrene of the vesical 
mucosa. In these conditions, secondary to retention, 
the patient may sink into a typhoid state and die, the 
condition being modified by a greater or less degree of 
uraemic intoxication. Septsemia in its various forms 
may result. Debility and nervous exhaustion from pain 
and loss of sleep in combination with the depressing 
effects of urinary intoxication or fever, are impor- 
tant elements in the production of a fatal result in all 
cases. 

Stricture, per se t is not capable of producing a fatal 
result, but it may and often does produce the conditions 
which have been mentioned, which, in addition to the 
effects of various complicating pathological states are 
sufficient to distroy life. 

Notwithstanding what has been said regarding the 
serious character of marked cases, it is surprising how 
rapidly some apparently desperate cases of stricture 
will improve, when once the obstruction has been re- 
moved. Even when the kidneys are seriously impaired, 
the constitutional symptoms marked and the secondary 



PROGNOSIS OF STRICTURE. 1 33 

bladder changes severe, the patient may improve with 
wonderful rapidity, as soon as the patency of the ure- 
thra has been restored. The improvement in the pa- 
tient's general condition is often times remarkable. 
The very gradual involvement of the upper portion of 
the genito-urinary tract in the secondary pathological 
conditions in stricture, probably explains the tolerance 
of the patient for quite severe renal and bladder changes 
— it may also explain to a certain extentthe promptness 
of the improvement after cure of the stricture. 

A condition not usually recognized in stricture is 
the greater or less marked toxaemia due to the constant 
absorption of ptomaines and toxalbumen from behind 
the point of obstruction. This toxaemia has much to do 
with numerous little ailments of which the patient may 
complain, but which he rarely atributes to his stricture 
until the cure of the latter suggests the cause of numer- 
ous other disturbances, by the fact -of their sudden and 
complete disappearance. This toxaemia too, constitutes 
a constant predisposition to urethral chill. The nervous 
system is loaded, so to speak, and ready for an explo- 
sion which instrumentation is often times all sufficient 
to bring about. 



CHAPTER VIII. 



THE TREATMENT OF STRICTURE. 

GENERAL MANAGEMENT AND SELECTION OF METHOD. 

The successful treatment of stricture of the urethra 
is dependent not only upon the proper selection of sur- 
gical methods of management and skill in their per- 
formance, but to a greater degree upon the manner in 
which the general management of the case is conducted. 
Careful attention on the one hand, or neglect on the 
other, may determine the success or non-success of sur- 
gical treatment. Thus dilatation may fail of its object, 
because of irritability or resiliency of a stricture, which 
attention to certain details in the general management 
of the case might avoid. Urethrotomy, divulsion, or peri- 
neal section may result fatally, because of failure on the 
part of the surgeon to carefully study the condition of 
other portions of the genito-urinary tract and of an in- 
appreciation of the general and local conditions pre- 
vailing at the time of the operation. 

In no disease of the genito-urinary tract is attention 
to genito-urinary and sexual hygiene more essential 
than in the management of stricture of the urethra. 
Regulation of the diet, temperate habits, sexual moder- 
ation or abstinence, and avoidance of exposure to cold 
and wet, are all important. The use of tobacco should 
be interdicted as tending to induce general irritability 

and hyperesthesia. I believe, moreover, that it is 

135 



I36 STRICTURE OF THE URETHRA. 

especially irritating to the genito-urinary tract. Chilling 
of the feet and legs is apt to be especially injurious, its 
effect upon stricture, in the production of acute hypere- 
mia and inflammation, being precisely similar to its 
results in enlargement of the prostate, in which disease the 
disastrous effects of exposure are so well known. The 
administration of alkalies for the purpose of neutralizing 
the urine is essential in the majority of cases. When 
pronounced cystitis exists, certain remedies will be found 
beneficial by preventing decomposition of the urine 
and consequently lessening its irritating properties. 
Boracic acid in ten or fifteen grain doses several times 
daily, napthalin, creosote in small doses, oil of eucalyp- 
tus, benzoate and salicylate of soda and in some in- 
stances small doses of turpentine, are useful for this pur- 
pose. In my experience the oil of eucalyptus in 10 min- 
im doses has been of especial value. The activity of 
the skin should be promoted by Turkish baths and rub- 
bings. The effects of sudden atmospheric changes 
should be avoided by wearing warm flannel garments 
of uniform weight. Exercise should be taken in mod- 
eration; fatigue and over-exertion should be avoided — 
perfect rest may possibly be indicated. 

Certain local measures are very essential in the 
management of stricture. A tendency to spasm and 
congestion at the site of the stricture may be prevented 
by the daily use of hot sitz-baths or the occasional 
application of leeches to the perineum. As a matter of 
routine, I advise my patients to take a hot sitz-bath 
nightly before going to bed. By proceeding in this man- 
ner, it will be found that the majority of cases of stric- 
ture will be much more tractable than under ordinary 
circumstances. In some cases of very tough, resilient 
stricture, the canal may be dilated much more readily 
if the patient be directed to take an injection of water 
as hot as can be borne night and morning. These in- 
jections should be kept up for half an hour at a time, 



SELECTION OF METHOD. 1 37 

and may advantageously be made antiseptic by the ad- 
dition of bichloride of mercury i in 20,000, or boric 
acid in saturation. 

Where manipulations of the canal tend to excite 
urethritis, hot bichloride irrigations, as recommended for 
chronic urethritis, may be cautiously employed. The 
various balsamic preparations are of service in such 
instances. 

Pain and spasm may be excited by each attempt at 
dilatation, in spite of the general measures already recom- 
mended. Under such circumstances, a small dose of 
morphia may be given hypodermically, by suppository, 
or by the mouth, a short time before the operation. 
When each operation tends to produce urethral chill or 
fever, the administration of opium has a decidedly con- 
servative and prophylactic effect. I have found that in 
these cases of irritable stricture with a predisposition to 
urethral fever, thorough irrigation of the canal with a 
hot bichloride solution before and after the introduction 
of a sound or before cutting operations, as the case 
may be, will generally obviate the difficulty. I desire 
particularly to call attention to the advantages of 
this procedure, as it will certainly tend to prevent the 
septic element in the production of urethral fever, Qui- 
nia, jaborandi, eucalyptus and diuretin are probably all 
serviceable as prophylactics against chill, but I have 
found the eucalyptus particularly valuable. 

SELECTION OF METHOD. 

The various forms of treatment which have been re- 
commended for stricture are as follows: 

1. Caustics. 

2. Continuous dilatation. 

3. Gradual dilatation. 

4. Dilating urethrotomy, or a combination of sec- 
tion and rupture. 



I38 STRICTURE OF THE URETHRA. 

5. Divulsion or rupture. 

6. Internal urethrotomy. 

7. External perineal section or urethrotomy with 
a guide. 

8. External perineal section without a guide. 

9. Electrolysis. 

10. Subcutaneous section. 

n. Excision, with or without a plastic operation. 

CAUSTICS. 

The treatment of stricture by caustics is a relic of 
surgical barbarism, and is hardly worthy of serious at- 
tention. The objects for which it was originally recom- 
mended were (1) the destruction of the stricture, and 
(2) diminution of the sensibility of the mucous mem- 
brane for the purpose of allaying irritability and spasm 
of the canal. The substance used was generally caus- 
tic potash. Whatever the results may have been, 
as far as restoring temporarily the calibre of the 
canal was concerned, the inevitable consequence of such 
atrocious surgery must necessarily have been the substi- 
tution of a chemical stricture for an ordinary organic 
one. As is well known, stricture due to actual destruc- 
tion of tissue is the most severe form with which we 
are called upon to deal. All the other methods of treat- 
ment which have been enumerated have their advo- 
cates at the present day — either as a matter of routine 
or a range of treatment from which to make a selec- 
tion — and may under proper circumstances be practised 
with advantage in different cases. The selection of the 
method is necessarily — within certain limits — a matter of 
choice on the part of the individual surgeon. The vari- 
ouslegitimate methods will receive special consideration 
after their applicability to the various forms of stricture 
has been outlined. 



STRICTURE OE THE MEATUS. 



139 



For practical purposes the surgical treatment of 
stricture may be divided into that of, 

'a. Simple uncomplica- 



1. Stricture of the mea- 

tus. 

2. Stricture of the pen- 

ile urethra. 

3. Stricture of the deep 

urethra. 



ted stricture. 

b. Irritable stricture. 

c. Resilient and elastic 
stricture. 

d. Recurrent stricture. 

e. Dense and hard tor- 
tuous stricture. 

f. Complicated stric- 
ture. 

, g. Traumatic stricture. 

To a certain extent the treatment of each particu- 
lar case is modified by the calibre of the contraction; 
for example, in tight strictures which it seems advisable 
to treat by dilatation, metallic instruments should not 
be used until a moderate amount of dilatation has been 
attained. The treatment is further modified by the 
occurrence of complications, such as false passages, reten- 
tion of urine, severe cystitis and pericystitis, infiltration 
of urine and abscess, fistulae, enlarged prostate, etc. 

STRICTURE OF THE MEATUS. 

Irrespective of their causation, strictures at the ex- 
ternal orifice of the urethra require free division by the 
knife. Attempts at dilatation are absolutely useless and 
simply serve to produce irritation. The peculiar struc- 
ture of the meatus is such that it cannot be permanently 
stretched, and attempts to do so not only produce local dis- 
turbance, but also reflex irritation and spasm of the deep 
urethra. The proper method of performance of meato- 
tomy,has been outlined as an essential preliminary to the 
proper exploration of the urethra. Any meatus which 
prevents the introduction of an instrument of sufficient 
size to distend the remainder of the canal to its extremest 



I40 STRICTURE OF THE URETHRA. 

capacity, must be considered as in a strictured condition. 
As already remarked, stricture of the meatus may be a 
relative affair— this is particularly true of the congenital 
form, which assumes surgical importance only in case 
of the occurrence of organic or functional diseases of the 
urethra behind it. In all cases of obscure nervous affec- 
tion, with concomitant symptoms referable to the sexual 
organs, it is wise to perform meatotomy, for whether 
or not there exists apparent irritation at the meatus, 
the effect produced upon the nervous system is frequent- 
ly strikingly beneficial; that this effect may sometimes 
be a moral one is admitted. 

In many instances of narrow meatus, the urethra 
behind it may be demonstrated to be in a pouched con- 
dition, by exploration with a bent probe. In this pouch, 
inflammation goes on indefinitely, its perpetuation 
being facilitated by the accumulation and decomposition 
of a few drops of residual urine. Meatotomy, therefore, 
often cures a most obstinate gleet. 

STRICTURE OF THE PENILE URETHRA. 

Strictures in the pendulous portion of the urethra 
give rise to greater annoyance to the patient, and more 
perplexity to the surgeon on the average, than those of 
the perineal portion of the canal. They are, however, 
obviously less dangerous, and their direct and remote 
results are less serious, than those occuring deeper down. 
They comparatively rarely contract so markedly as to 
produce serious obstruction to the flow of urine, and 
where they form slowly, we often meet with cases in 
which several comparatively tight strictures exist, but 
have produced little or no trouble, having been either 
discovered accidentally or during an exploration for the 
purpose of determining the cause of an inter-current 
simple urethritis. I have recently operated upon a 
young man who had three strictures of the pendulous ure- 
thra, the tightest of which would barely admit the closed 



STRICTURE OF THE PENILE URETHRA. I41 

blades of the dilating urethrotome. These strictures 
had produced no inconvenience whatever, and probably 
would have remained undiscovered for some little time, 
if the patient had not, at the suggestion of a friend, 
submitted "himself to an examination, for the purpose of 
ascertaining whether by any possibility a gonorrhoea 
which he had contracted some years ago, had left any 
permanent results. Such a passive condition of stric- 
tures in this situation is of course, not to be expected, for 
as a rule, they give rise to considerable annoyance, to 
frequent attacks of so-called "bastard clap," or to an 
indefinate perpetuation of gleety discharge. 

Although strictures in any portion of the canal are 
apt to give rise to more or less marked vesical irritation, 
the liability to this annoying symptom seems to be in 
direct ratio to the distance from the meatus. Com- 
paratively slight strictures in the deep urethra will pro- 
duce by direct irritation through contiguity of structure 
and nervous supply, annoying frequency of micturition. 
In occasional cases however, this symptom is the prin- 
cipal feature of a stricture at or near the meatus. 

The degree of contraction in penile strictures is very 
variable. It is rather exceptional than otherwise, that 
such strictures are contracted to so marked a degree as 
is frequently noted in the deep urethra. This state- 
ment may seem tobe at variance with the experience of 
many surgeons, but the discrepancy is explicable by the 
fact that the majority of surgeons do not recognize that 
vast number of cases in which stricture of large calibre 
exists. When I speak of the relative rarity of stricture 
of small calibre in the penile portion of the urethra, I 
mean as compared with the total number of those which 
may be observed by careful exploration with the bul- 
bous bougie. 

Stricture of the pendulous urethra is very apt to be 
multiple. Indeed, there are few cases in which a full 
sized bougie or the urethrameter fails to detect two or 



142 STRICTURE OF THE URETHRA 

more points of contraction in different parts of the canal. 
These strictures are frequently irritable, and almost 
always resilient. They are a potent cause of chronic 
urethritis and gleet, and explain the obstinacy of very 
many apparently incurable cases of urethral discharge. 
Even when they are not, strictly speaking, the cause of 
the chronic inflammation, they invariably tend to per- 
petuate it. If the profession had nothing else for which 
to thank Dr. Otis, it would still be under lasting obli- 
gations to him, for his demonstration of the true patho- 
logical condition in the majority of those obstinate cases 
of gleet, which have so long been the bete noir of the 
su rge o n . When such strictures are irritable, as they are very 
apt to be } a very slight exciting cause is sufficient to excite 
tcrethritis, the severity of which depends upon the de- 
gree of irritation. In short, penile strictures of large 
calibre may be said to constitute a constant predisposi- 
tion to both virulent and simple urethritis. 

Dr. Otis' remarks upon the subject of gleet and its 
relations to urethral stricture are of the greatest practi- 
cal value and well worthy of reproduction. 

"The secretion of the urethral mucous membrane 
serves as a protector and lubricant for the preservation 
of this membrane from the contact of the irritating uri- 
nary fluid. It is made up of germinal granules — par- 
ticles of bioplasm (Beale) which rise up through the 
interstices of the sub-mucous cellular tissue, are trans- 
uded through the basement mucous membrane and 
become organized as the protective and lubricative 
epithelial cells of the urethral mucous membrane, and 
where the conditions of its evolution are in every 
respect perfect, in quantity just sufficient for the lubri- 
cation and protection of this structure. This is never 
sufficient to be perceptible to the naked eye, except as 
a moist glazing of the surface. Any excess is always 
the result of an abnormal stimulation of the natural 
processes, except in a single instance, purely physiological, 



STRICTURE OF THE PENILE URETHRA. 1 43 

when it proceeds from an erotic excitement and 
appears at the meatus as a transparent mucous exuda- 
tion which passes off with the cessation of the nervous 
impression which provoked it. The causes which unduly 
increase the secretion of this membrane (and in speak- 
ing of the mucous membrane I include the glands, 
crypts, and follicles made up of its local reduplications) 
are to be divided into two classes: first, active inflamma- 
tion set up by contagion or clap, and second, mechani- 
cal injury or some obstruction, as urethritis from lodge- 
ment of a calculus, injuries caused by instrumental vio- 
lence or irritant injections, or urethral obstruction from 
chronic inflammation. 

The first effect of an approaching inflammation of a 
mucous membrane is an increase in the natural secre- 
tion. The mucous cells are hurried along through their 
different stages of development, and as the amount of 
secretion increases, it is less and less perfectly elabo- 
rated; the germinal material is drawn to the surface 
with increasing rapidity, until cells, which in health pass 
through a gradual development from the germinal 
granule to the fully formed epithelial scale, now appear 
as a mass of emasculated corpuscles, pus cells, which 
constitutes what we are accustomed to term, a purulent 
discharge. 

The inflammation is thus characterized during its 
continuance, whether arising from mechanical or chemi- 
cal causes. The character of inflammation in the urethral 
mucous membrane varies in degree rather than kind* The 
duration of the inflammation varies, as the cause is 
more or less vicious in its onset, or more or less persis- 
tent in its influence. 

The active stage of an inflammation of the urethral 
mucous membrane has a duration in the majority of 
cases of four or five weeks. In the cases where com- 
plete recovery does not take place within this time, there 

* Italics mine. 



144 " STRICTURE OF THE URETHRA. 

is usually a subsidence of the more acute symptoms and 
the case is then characterized by a painless or nearly 
painless discharge, more or less profuse and more or 
less purulent, which persists in spite of judicous treat- 
ment for weeks, perhaps months, often years; at times 
reduced to a mere secretion which sticks the lips of 
the meatus together, when upon a slight indiscretion 
in diet, or a little sexual or vinous indulgence, within a few 
hours it may return as a free and possibly painful puru- 
lent discharge. This form of urethritis, which has for 
time immemoral afflicted humanity, and which has 
probably been the source of more trouble to patients 
and surgeons than any other known difficulty, is famil- 
iarly known as gleet. 

This is usually considered as a sort of chronic gon- 
orrhoea and treated on the same general principles, (by 
internal remedies and local injections) or is looked upon 
as the result of a debilitation of the urethral mucous 
membrane but having no specific or contagious property 
associated with it, and is treated by specific and local 
means. Now, if it can be established that gleet is the 
result of a mechanical condition, that it may be pro- 
duced without the previous occurence of a gonorrhoea, 
by the simple obstruction of the free discharge of urine 
through the urethra, and which obstruction may oc- 
cur as a result of any inflammation or injury which im- 
plicates the sub-mucous urethral tissues, it will than be 
clear that no treatment which is not based upon the 
detection and removal of the mechanical difficulty can 
be more than palliative. And if it can be shown that 
the detection of contraction is possible in all cases of 
gleet, and that its removal is certain to cure the gleet, 
the proof of the non-specific character of gleet may be 
considered to be established. 

While I am certain that a variety of remedies, local 
and general, may, when judiciously employed, enable 
the patient to pass through gonorrhoea with much more 



STRICTURE OF THE PENILE URETHRA. 145 

comfort and less danger of subsequent trouble than 
without treatment, yet I am prepared to state as my 
opinion based upon a large personal experience, that it 
is a self limited disease in its acute form, and when it 
lasts longer than four weeks, or when apparent recovery 
takes place and the discharge breaks out afresh without 
new exposure, that there is a complication present, either 
as a result of the current inflammatory trouble, or of 
some inflammation antecedent to the attack, which 
causes the continuance of the trouble, and which must be 
appreciated and removed before any permanent cure 
can be had. This complication is urethral stricture — 
stricture in the sense of an abnormal contraction of the 
urethral calibre at some point at or between the meatus 
urinaris and the bulbo-membranous junction; and I will 
further state it as my conviction, that the continuance 
of the inflammatory trouble (and wherever there is a 
urethral discharge, there is incontestibly more or less 
inflammatory trouble) is due to the* irritation kept up 
by the arrest, more or less complete, of the stream of 
urine at the point of stricture and by the imperfect 
emptying of the urethra after urination. 

Chronic gonorrhoea — gleet — is dependent as a rule 
on abnormal contraction of the urethral canal. 

Chronic urethral discharge mea7is stricture. I am 
quite aware that well defined stricture may be present 
without a palpable discharge, but there is always to be 
found evidence of a certain degree of irritation present 
in all such cases, although there may be no appreciable 
discharge. When, however, there is discharge, there 
will in every case be found, if the examination be effi- 
ciently made, a well defined and unmistakable point of 
stricture." 

After stating that the ordinary sound is practically 
valueless for diagnostic purposes, Dr. Otis says that 
proper exploration means the use of the bulbous bougie 
or the urethrameter. This is not too arbitrary a position 



I46 STRICTURE OF THE URETHRA. 

by any means, and must meet with the unqualified 
endorsement of every surgeon who has command of the 
subject. 

There are some points in Dr. Otis' arguments that 
cannot be accepted unhesitatingly. He asserts that 
gonorrhoea has a self limited course when uncomplicated, 
this course comprising a period of about four weeks, 
and that cases running over this time are complicated, 
usually by recently formed or antecedent stricture. This 
view implies a specificity and a limitation of course of 
gonorrhoea that few will be willing to admit. Compli- 
cations or no complications, there is the greatest varia- 
tion in the course and duration of gonorrhoea, even 
when several observed cases are due to the same source 
of infection. In order to determine the exact normal 
course of the disease, a series of patients would be re- 
quired who could be confined to bed and placed under 
precisely the same conditions as regards diet, sexual 
excitation, rest, etc. This would confessedly be diffi- 
cult of accomplishment. Were this scheme practicable, 
there would even then, in my opinion, be found a wide 
variation in the duration of the cases. I cannot believe 
that so arbitrary a statement as that of Dr. Otis, to the 
effect that a case of over four weeks duration means 
complications — and usually stricture, — is warranted by 
the facts. 

Admitting that there are complications of one kind 
or another in cases of over four weeks duration, it is 
hardly fair to assume that stricture is nearly always 
responsible for the prolongation of the case, unless the 
contractions found are admitted to be points of nonnal con- 
traction, which have become abnormally virtue of the path- 
ological state of the mucous membrane, and which are capa- 
ble of prolonging the latter. Looked at from this stand- 
point, stricture is certainly, in by far the majority of 
cases, the cause of perpetuation of a gonorrhoeal dis- 
charge. Clinically, such points should be looked upon 



STRICTURE OF THE PENILE URETHRA. 147 

in the same light as true adventitious stricture deposit, 
after a reasonable time has elapsed during which thorough 
medication, both general and local, has been carried on. It 
certainly would not be wise to condemn a urethra to 
operation, even though definite contractions have been 
detected, until several months careful treatment have 
proved inefficacious, especially in first attacks of gon- 
orhcea. 

Dr. Otis fails to recognize as important, the ele- 
ment of posterior urethritis in the perpetuation of gleet. 
There is hardly any question that inflammation of the 
deep urethra is often responsible for frequently recurring 
re-infections of the anterior canal. As a matter of com- 
mon experience it is found that posterior urethritis is 
quite frequently responsible for a gleet with acute exacer- 
bations, which lasts for months, or perhaps indefinitely, 
after the supposed cause — urethral stricture — has been 
removed. It is true that a persistent gleet after urethro- 
tomy often means an imperfect operation, but that this 
inference is not always just, is shown by the experience 
of many keen observers. 

Another point which must be considered, is that we 
meet with many, many instances where men have had 
gonorrhoeas galore in their youth, the discharge often 
times having been of very long duration, yet they have 
never had symptoms of stricture. It is possible — nay, 
probable — that the urethrameter will show in all these 
cases, contractions of the canal, but the individual goes 
through life without ever realizing that he has any 
morbid condition of his urethra. It is well not to be 
hasty regarding operative procedures in gleet follow- 
ing first attacks of gonorrhoea. One may well be cau- 
tious here, whilst he would be foolish to temporize with 
a case in which frequent attacks have occured. He 
would be presumptious indeed, who would attempt to 
bumptiously combat Dr. Otis' teachings. He has un- 
doubtedly done more for urethral surgery than any 



I48 STRICTURE OF THE URETHRA. 

surgeon of this day and generation, but as is true of all 
teachers of a new theory, there is danger that his pre- 
cepts may lead to too arbitrary conclusions. That I 
appreciate fully the doctrines of Dr. Otis regarding the 
relation of gleet to urinary obstruction, is shown in my 
remarks upon the relation of points of normal relative 
indistensibility to pathological states of the mucous 
membrane of the urethra. 

The more important of the conditions which, in 
addition to stricture, must be taken into account in 
estimating the causes of gleet are as follows : 

1. Constitutional debility. 

2. Intemperance, both alcoholic and sexual. 

3. The gouty and rheumatic diatheses. 

4. Tuberculosis of the genito-urinary tract. 

5. Chronic superficial urethritis, with or without 
distinct erosions. 

6. Peri-urethritis or loss of elasticity — nascent 
stricture. 

7. Folliculitis and chronic inflammation of lacunae. 

8. Cowperitis. 

9. Posterior urethritis, i. e. prostatitis folliculosa. 

10. Chronic abscesses from peri-urethral phleg- 
mon. 

11. Urinary fistulas. 

12. Neoplasmata. 

Admitting stricture to be the most frequent cause 
of gleet, the above conditions are still worthy of the 
most discriminating attention. 

There is one point which should be constantly borne 
in mind, and that is, as already intimated, that the fact that 
the urethra will permit the introduction of a large sized 
steel sound, is no evidence that stricture is not present, 
for it will often be found upon exploration with the 
bulbous bougie in such cases, that one or more strictures 
of large calibre exist. I am constantly operating upon 
cases of this kind. In a recent case the urethra was 



STRICTURE OF THE PENILE URETHRA. 1 49 

dilated sufficiently to admit an 18 English sound, yet upon 
the slightest sexual excitement or indulgence in liquor 
a free discharge occured. On exploration with the bul- 
bous bougie I found a resilient stricture of large calibre 
at a depth of 3^ inches from the meatus. The pres- 
ence of this stricture explained the stubbornness of the 
case, and I therefore suggested and performed internal 
dilating urethrotomy with a successful result. 

The pronounced tendency to irritability and resili- 
ency on the part of strictures of the pendulous portion of 
the urethra constitutes the principal obstacle to successful 
treatment by dilatation. I have found that dilatation 
in cases of stricture in this portion of the canal is usually 
disappointing, and that the patient either does not get 
entirely well of his gleet, or he apparently does so, only to 
experience a recurrence of urethritis upon the super- 
vention of the slightest exciting cause. I venture the 
opinion that very few cases of stricture of this kind are 
ever thoroughly cured, excepting by cutting, and expe- 
rience has impressed upon me the necessity of radical 
interference and the uselessness of temporizing by dila- 
tation. I therefore would advise urethrotomy in all 
marked cases, and in the slighter forms where the con- 
tractions do not readily yield. When stricture is young 
and soft — i. e., of recent date, and not yet fully organ- 
ized — dilatation offers a good prospect of a cure, and it 
is but just that the patient be given the benefit of the 
doubt and an attempt be made to cure the condition 
without the radical operation. In old cases, no matter if 
they be apparently slight, dilatation is not apt to be 
successful. 

The prospect of cure of penile strictures by dilatation 
is directly proportionate to their distance from the meattcs. 
Strictures located anywhere between the meatus and a 
depth of 2% inches, bear almost the same relation to 
dilatation, as far as the prospect of a cure is concerned, 
as do strictures directly at the meatus. 



I50 STRICTURE OF THE URETHRA. 

When a stricture of the penile urethra is of small 
or moderate calibre, that is, below 15 or 16 French, it 
is often advisable to begin the treatment by dilatation 
with soft instruments, just as would be done in stric- 
ture of the fixed urethra. If desired, the dilatation maybe 
carried up to a point where the resiliency of the stricture 
begins to manifest itself ; urethrotomy then becomes 
necessary. Some cases will apparently dilate readily at 
each sitting; but little progress can be made, as re-con- 
traction seems to occur during the intervals between 
the operations of dilatation. The canal may be dilated 
apparently to its fullest capacity, so that it will admit a 
large sized sound, and the patient may be discharged, 
yet in a short time he will return to his surgeon com- 
plaining of a recurrence of urethritis. In such cases ex- 
ploration with the bulbous instrument from time to time 
will show whether the stricture is really absorbing or 
not. When improvement is not steady and permanent, 
resiliency of the stricture may be suspected, no matter 
how large a sound the urethra may admit. The only way 
to proceed in such cases is to perform a cutting opera- 
tion. The resiliency and elasticity just described are 
rarely met with in strictures of the deep urethra. They 
are, however, the rule in those occurring in the penile 
portion of the canal. The fact that dilatation is so un- 
successful when applied to strictures of the penile por- 
tion, as compared with those of the deep urethra, is 
probably explicable by anatomical differences in the 
location of the stricture. In some cases of stricture of 
the penile portion of the canal, the thickening and indu- 
ration occur principally in the structure of the mucous 
membrane proper and just beneath it, rather than in the 
erectile tissue, and moreover, the process occurs at a 
point of normal inelasticity of the canal, i. e., at a point 
which nothing will dilate effectually. The infiltration 
which occurs in deep strictures is more extensive, and 
is located principally in the corpus spongiosum, beneath 



STRICTURE OF THE PENILE URETHRA. 151 

the mucous membrane at a point where the urethral 
walls are thick. It is located, moreover, upon each side of 
the bulbo-membranous junction and chiefly anterior to 
it, rather than at a point which exactly corresponds to it. 
The pressure of the sound produces absorption at this 
point on account of the thickness and succulency of the 
tissues and the abundance of the absorbents. Stricture 
of the mucous membrane of the deep urethra is not so 
apt to be produced by strong injections as it is in the 
penile portion. Virulent inflammation is not so severe 
in the deep urethra, as a rule, as it is in the anterior 
portion of the canal. 

When the urethral mucous membrane is severely 
abraded, the consequent stricture is invariably tougher 
and more inelastic than under ordinary circumstances. 
Stricture of the penile urethra is very much like trau- 
matic stricture in this respect; it will be found to be 
precisely like the latter — or nearly so — in respect to its 
amenability to treatment by dilatation. 

Another point which is not generally recognized, is 
the relative unrest of a stricture in the penile urethra, 
incidental to varying conditions of blood supply and 
erection. 

The treatment of stricture of the penile urethra may 
may be briefly summed up as follows: 

1. Those located within 2^ inches from the mea- 
tus cannot possibly be cured by dilatation, and must 
be cut. 

2. Pronounced cases in any portion of the penile 
urethra must be cut, either immediately or after prelimi- 
nary dilatation, in by far the majority of cases. 

3. The treatment of marked cases, i. e., those of 
small calibre, may be begun by continuous or gradual 
dilatation with soft instruments up to the size of 15 or 
16 French, or even larger, and in some cases it may be 
advisable to continue the dilatation with steel instru- 



152 STRICTURE OF THE URETHRA. 

ments beyond this point, until the stricture shows irri- 
tability. 

4. Strictures of large calibre, strictures of recent 
formation, and those consisting of points of normal in- 
elasticity which are perpetuating gleet, may be treated by 
dilatation, the patient being forewarned that the treat- 
ment is apt to prove unsuccessful, and that urethrotomy 
will probably be required either within a short time, or 
later on, on account of a recurrence of urethritis depend- 
ent upon the contraction. In other words, the patient 
should be informed that the treatment by dilatation, 
although it may prove efficacious in temporarily reliev- 
ing the gleet and other symptoms of stricture, may, at 
the same time fail to produce a satisfactory result, and 
that he will constantly be predisposed to attacks of in- 
flammation from the slightest indiscretion. Should the 
patient be satisfied with treatment of this kind, it is 
hardly wise for the surgeon to insist upon an operation. 

By the term internal urethrotomy in connection with 
strictures of the pendulous tcrethra, I mean the combined 
operation of dilating urethrotomy according to the Otis 
method. 

STRICTURE OF THE DEEP URETHRA. 

Stricture of the deep urethra, implies those contrac- 
tions which involve that portion of the urethra em- 
braced within the limits of what has been termed by 
Thompson, the bulbo-membranous region. Strictures in. 
this location are much more important with reference 
to the frequency of occurrence of those serious secondary 
and complicating conditions which are intrinsically dan- 
gerous to life, than are those which are met with in the 
anterior portion of the canal. It may be accepted as an, 
invariable rule, that the gravity of stricture is directly pro- 
portionate to its distance from the meattts. The struc- 
tures surroundingstricturesof the deep urethra are thick 
and vascular, and operations for their cure are a much 



STRICTURE OF THE DEEP URETHRA. 1 53 

more serious matter than in other portions of the canal. 
The various complicating conditions which are apt to arise 
in the course of stricture of the urethra, are not only 
most likely to arise in these cases, but they involve such 
important structures that the most disastrous results are 
occasionally produced by them. The selection of the 
method of treatment becomes therefore a question of 
vital importance, and in a general way it may be said, 
that the more cautious and conservative the surgeon, 
and the more delicate his manipulations, the more likely 
he is to obtain a successful result. A most careful study 
of the case is necessary to determine the probable 
existence of serious vesical, and more particularly of 
renal complications, prior to beginning surgical inter- 
ference. The duration, condition and calibre of the 
stricture, and the habits and general condition of the 
patient must receive most careful attention, as they will 
serve as excellent criteria for the selection of the 
method of treatment and for the guidance of the sur- 
geon in the conduct of the case. 

In strictures of small calibre which have existed 
for a considerable time, particularly in patients of 
intemperate habits and cachectic constitution, serious 
disturbance of the structure and function of the kidneys 
is to be inferred, independently of the revelations of uri- 
nalysis. Even in cases of stricture of comparatively 
large calibre in this situation, the greatest care should 
be exercised if the patient be at all broken down in 
health, is intemperate, or if the stricture is of long 
standing. Although in the majority of cases the dan- 
ger of secondary and complicating conditions is directly 
proportionate to the degree of contraction, it must be 
remembered that the fibrous deposit at the site of the 
stricture, forms and contracts much more readily in some 
patients than in others, so that in some cases a stricture 
of comparatively short duration may be of very small 
calibre, while in others which have lasted for a much 



154 STRICTURE OF THE URETHRA. 

longer time there may be comparatively little contrac- 
tion. Other things being equal, however, the tighter 
the stricture, the greater the danger of renal complica- 
tions, yet in cases of slow forming stricture of large 
calibre, the bladder and kidneys maybe in a much more 
serious condition than in other cases of small calibre, 
in which the contraction has occurred quite rapidly. 

In selecting the method of treatment, the surgeon 
should be influenced by the fact, that no method of man- 
agement of these deeper strictures, has yet been gen- 
erally accepted as affording a prospect of a permanent 
cure. Inasmuch, therefore, as radical operations do not 
promise a result sufficiently successful to counterbalance 
their dangers, we should, it seems to me, lean towards 
ccnservatism. If an approximately successful result 
can be obtained by simple and conservative measures, 
it is certainly unfair to subject the patient to the dan- 
gers of a radical procedure, particularly as the latter 
promises little if any more favorable results than con- 
servatism. As far as my personal feelings are con- 
cerned I believe that the surgeon should for the nonce 
place himself in the patient's position and consider 
what method of treatment he would himself be willing 
to submit to, were he in a similar condition. He prob- 
ably would not be inclined to submit to a dangerous 
operation, if there were any possibility of being relieved 
by simpler measures, even though it were necessary to 
continue the latter for the remainder of his days. 

Simple ^Lncomplicated stricture of the deep urethra 
should be treated by dilatation. If the stricture be of 
small calibre, it may be necessary to begin the treatment 
by the method of continuous dilatation with soft instru- 
ments, one instrument after another being introduced 
in increasing sizes, until the stricture is dilated as far as 
possible without the use of undue force. If a soft 
instrument is allowed to remain in the urethra for a few 
minutes, it will be found that the next larger size can, 



STRICTURE OF THE DEEP URETHRA. 1 55 

as a rule, be quite easily introduced. In cases in which 
a small instrument is introduced with difficulty, it may 
be left in the canal for from six to twenty-four hours, at 
the end of which time sufficient absorption of the stric- 
ture will have occurred to permit of the introduction of 
a larger instrument and to permit of the passage of the 
urine beside the instrument while in situ. This is a 
desirable method for the treatment of some cases of 
tight stricture in which there is considerable congestion 
and a tendency to spasm, it being oftentimes rather 
hazardous to introduce and immediately remove an 
instrument for the purpose of exploration or dilatation, 
because of the danger of spasmodic or congestive reten- 
tion coming on within a few hours thereafter, as a con- 
sequence of reaction. After the stricture has been 
dilated to a certain extent, this is not so likely to occur. 
Gradual dilatation performed in a conservative manner, 
with due regard to general and. local measures for 
the correction of general nervous sensitiveness of the 
patient and irritability or congestion or the lesion, will 
usually bring about what is practically a cure, in by far 
the larger proportion of strictures of the deep urethra. 
Anaesthetics are sometimes necessary for the pur- 
pose of facilitating dilatation. In very many persons, 
as a consequence of nervous excitement and fear, there 
will be excited by the passage of the instrument so much 
reflex spasm, that a comparatively small bougie will pro- 
duce considerable bruising and inflammation at the site 
of the stricture. In such patients anaesthetics may be 
required ; the preliminary administration of morphine 
is, however, often successful. It is certainly exceptional 
that radical operations become absolutely necessary, for, 
given a patient who is able and willing to visit the sur- 
geon, or be visited by him, as frequently as may be 
required, and an operator who has an abundance ot 
patience as well as expertness in urethral manipula- 
tions, gradual dilatation is generally perfectly success- 



I56 STRICTURE OF THE URETHRA. 

ful, or at least as satisfactory as any method of treat- 
ment has yet proven to be. The surgeon who regards 
the urethra as an insensate tube which is susceptible of 
the various operations of divulsion, cutting and forcible 
dilatation, without resentment, is the one who is able 
to report the largest number of cases of radical opera- 
tions for stricture. In direct proportion to the degree 
of gentleness and patience which is exhibited in the 
management of strictures of the deep urethra, will be 
the satisfaction experienced in their treatment, although 
our lists of wonderful radical operations will be limited 
thereby. 

With all the patience, perseverance and gentleness 
which can possibly be brought to bear however, cases 
occasionally occur which are not susceptible to treat- 
ment by simple dilatation. In some cases the tissue of 
the stricture is highly contractile and elastic, and resents 
dilatation beyond a moderate degree, all attempts at 
further stretching and absorption being followed by 
chill, exacerbation of urethritis or painful vesical symp- 
toms. It may apparently dilate quite readily, and 
yet immediately recontract as soon as the dilatation is 
suspended for a time. In some patients, so much pain 
and irritation are produced by instrumentation that it is 
impossible to carry out the treatment by dilatation as it 
should properly be done. This condition of affairs 
rarely exists in simple stricture, but is frequently 
observed in those of the complicated variety. 

The conditions requiring measures of a more 
radical character than simple dilatation are as follows : 

1. Irritable Stricture : In this form of the disease 
the patient is usually of a highly nervous and irritable 
temperament and the urethra is extremely hyperaes- 
thetic. Every attempt at dilatation is attended by 
severe pain and spasm — sometimes with general con- 
vulsive manifestations — and followed by chill, and per- 
haps more or less fever. Such strictures are also 



RESILIENT AND ELASTIC STRICTURE. 1 57 

resilient and present a marked tendency to congestion 
and inflammation, so that attempts at dilatation are 
not only unsuccessful, but it will be found that it will be 
impossible to pass instruments which perhaps were 
admitted with only a moderate amount of difficulty at 
a previous sitting. Strictures of this kind are usually 
of small calibre. 

2. Resilient and Elastic Stricture : Although often 
irritable this form may be dilated quite readily without 
the occurrence of the symptoms just described, until 
the urethra is apparently dilated to its fullest capacity. 
The symptoms, however, are not completely relieved, 
and on exploration with the bulbous bougie it will be 
found that although a large sized sound has passed quite 
readily, the stricture is still present and is detected 
without difficulty. This condition of affairs is compar- 
atively exceptional in the deep urethra, being more 
frequent in the penile portion, still it is occasionally 
met with deeper down. 

3. Recurrent Stricture: This form is really a variety 
of resilient stricture in which the resiliency or elasticity 
does not immediately manifest itself. Such strictures 
re-contract within a very short time after the cessation 
of treatment, either spontaneously or as a consequence 
of the occurrence of some slight exciting cause. As a 
rule, resilient, elastic and recurrent strictures do not 
exhibit their evil propensities until they have been well 
dilated, when they become exceedingly stubborn. Very 
often they are of comparatively large calibre. Other 
things being equal, I am more inclined to apprehend 
such behavior on the part of a stricture of large calibre 
than one of smaller size. Like the preceding form, 
recurrent stricture is more frequently seen in the penile 
portion of the canal, although occasionally seen in the 
deeper urethra. 

Recurrence of stricture is most rapid and most cer- 
tain to occur in gouty or rheumatic subjects. The 



I58 STRICTURE OF THE URETHRA. 

habits of the patient have a very important bearing 
upon this form of stricture. 

4. Very hard stricture of cartilaginous consistency 
and long duration: Strictures of this kind, although 
often traumatic, may arise from the ordinary cause, i. e. 
virulent urethritis. They are usually tortuous, and 
instruments can be passed only with great difficulty. 
Dilatation cannot be carried beyond a moderate degree 
owing to the density of the quasi-cicatricial tissue of 
which they are composed. Strictures of this kind will 
neither dilate — or at least if they do so at all they 
immediately recontract — nor can absorption be induced 
in them by pressure; a case of stricture in the deep 
urethra which involves half or three-quarters of an inch 
or more of the canal, is apt to present these charac- 
teristics. 1 

5. Hard and tortuous complicated stricture : Stric- 
tures of this kind are most apt to be complicated by 
serious retention, urethral rupture and urinary infiltra- 
tion or the formation of fistulae. There may be c@nsid- 
erable infiltration of plastic material, not only in the 
urethra, but in the cellular tissue of the perineum about 
it. There is invariably a formation of dense fibro-con- 
nective tissue about these parts if fistulae have de- 
veloped. 

6. Cases in which economy of time is necessary or the 
condition of the patient is such as to tcrgently demand 
relief : Non-resident patients who cannot afford the 
necessary time and expense involved in the treatment 
by dilatation must be included under this head. 

Irritable, resilient, and recurrent strictures of large 
calibre in the deep urethra are best treated by external 
section, although the combined method of urethrotomy 
and divulsion, a relatively small nick being made in the 
strictured tissue — just sufficient to facilitate rupture — 
sometimes gives good results. American surgeons, 
however, are fast giving up all cutting operations in the 



IRRITABLE STRICTURE. I 59 

deep urethra with the exception of external section. 
When strictures of this kind are of only moderately 
large calibre, the tissues being relatively dense and car- 
tilaginous, perineal section is especially to be preferred, 
although simple divulsion is often a successful opera- 
tion. The operation of divulsion is becoming de- 
servedly unpopular in America, but I can see no reason 
for tabooing it altogether. A careful and discrimi- 
nating selection of cases is of course necessary. For 
the general practitioner a divulsor is a dangerous article 
for his armamentarium ckirurgicum. 

It will be found in cases of irritable stricture that 
the more radical operations are productive of less con- 
stitutional disturbance upon the average than are 
repeated attempts at dilatation. The contracted aiid 
resilient stricture tissue is so intensely hyperaesthetic, that 
the slightest attempt to stretch it may produce serious 
results; whereas division by incision or rupture, relieves the 
hyperesthesia at once and produces comparatively little irri- 
tation, the danger from operation being rather of a direct 
character and incidental to the possible occurrence of sepsis, 
than to any remote impression produced through the medium 
of reflex nervous disturbance. 

The difference in the results obtained by stretching 
a contractured and highly sensitive fibrous structure, 
and completely dividing it, is well illustrated in certain 
cases of talipes, torticollis and other conditions in 
which fibrous, tendinous and muscular structures are 
shortened, and perhaps thickened, by interstitial con- 
nective tissue or fibrous deposit. Dr. Sayre, in his 
excellent work on Orthopcedic Surgery, calls partic- 
ular attention to this point ; indeed, his criterion of the 
necessity for a cutting operation in these various de- 
formities, is the spasm of the muscles and pain, pro- 
duced by pressure or percussion upon the part when 
put upon the stretch. The same rule in a certain sense 
might be applied to stricture, for when we find that 



l60 STRICTURE OF THE URETHRA. 

attempts at dilatation produce severe pain and reflex 
spasm, with perhaps constitutional manifestations of an 
alarming character, further attempts at dilatation are 
contra-indicated, and more radical measures involving 
division of the affected tissue by rupture or incision are 
called for. Complete rest for a time, occasionally com- 
pletely removes the element of irritability, with subse- 
quent facility of cure by dilatation. 

Very hard and cartilaginous deep strictures of long 
standing, whether complicated or not, require in my 
opinion, external perineal section. Especially is this 
true of cases complicated by serious bladder complica- 
tions. The simpler varieties of complicated stricture 
do not necessarily call for such radical measures. In 
these pronounced forms of stricture, divulsion or inter- 
nal urethrotomy are very dangerous as well as unrelia- 
ble operations. There is great danger of haemorrhage, 
the control of which is difficult on account of the depth 
of the operative lesion and the induration of the bleed- 
ing tissue, and also the special dangers of septic infec- 
tion, infiltration of urine, abscess and fistulae, due to the 
tearing by the operation, not only of the stricture but of 
the surrounding parts, these complications being favored 
by the heat of the tissues and the impossibility of main- 
taining a perfectly aseptic condition of the wound. 

Internal incision of dense strictures of the deep 
urethra fails of its object because of the fact that it is im- 
possible to introduce a cutting blade of sufficient size to 
thoroughly divide them. Indeed, in order to accom- 
plish complete division the incision would in some 
cases necessarily cut almost entirely through the 
urethra. The relation of urethrotomy to deep stric- 
tures, is entirely different from that which it bears to 
strictures in the penile portion of the canal. In the 
latter the blade of the urethrotome, when properly 
used, nearly or quite divides the strictured tissue, which 
involves in many instances — and invariably in strictures 



STRICTURE OF THE DEEP URETHRA. l6l 

of large calibre — only the mucous membrane and a 
more or less superficial layer of the tissues beneath it. 
It is of course admitted that there are many cases of 
penile stricture that are extensively undurated, but 
these are exceptions to to the rule. Dittel has shown 
some striking cases of this kind. In the dense varieties 
of stricture of the deeper portion of the canal, the 
blade of the instrument merely makes a comparatively 
superficial incision in the strictured tissue and does not 
completely divide it. It is obvious that complete rup- 
ture of strictures of this kind cannot be accomplished 
without considerable injury to the structure of the cor- 
pus spongiosum. Taking these things into considera- 
tion, external perineal section is to be recommended 
from the considerations that, (i) complete division of 
the strictured tissue is accomplished; (2) complete 
relief of retention, if such exists, is secured; (3) perfect 
drainage, and comparative facility "of maintaining an 
aseptic condition of the wound are provided for; (4) 
haemorrhage can be easily gotten at and subdued; (5) 
it is an indubitable fact that the result obtained by the 
operation is better and much more easily maintained 
permanently by occasional dilatation of the urethra, 
than when internal operations are performed. 

I have latterly adopted the view that there is less 
danger — even in the comparatively slight forms of stric- 
ture in the deeper portions of the urethra, in the per- 
formance of external perineal section than in either 
internal urethrotomy or divulsion. 

Cases demanding immediate interference on ac- 
count of the occurrence of retention, had best be treated 
by external perineal section. If, however, the* patient 
can be under the control of the surgeon, and there is a 
prospect of a favorable result from more conservative 
measures, the case should be temporized with in the 
manner that will be shortly outlined, until such time as 



l62 



STRICTURE OF THE URETHRA. 



it is practicable to begin treatment by dilatation. Non- 
resident patients with strictures of large calibre should 
be operated upon by the Otis method of dilating 
urethrotomy, or by divulsion. In certain selected and 
exceptional cases divulsion may be judicious. If the 
stricture be of small calibre external perineal section 
should be performed. In some cases of deep stricture, 
especially when complicated by retention, electrolysis 
i. e. galvanism is successful as a temporary measure, 
— as a preliminary to other treatment. 

To sum up, the treatment of strictures of the deep 
urethra may be formulated as follows : 



Simple stricture, small 

calibre. 

Large calibre. 



2. Resilient, Elastic and 
Recurrent Stricture. 



Hard, tortuous, old 
and complicated stric- - 
ture. ^' 



Continuous dilatation, fol- 
lowed by gradual dilatation. 
Gradual dilatation. 

Internal dilating urethro- 
tomy (exceptionally.) 

Divulsion (exceptionally) 
Perineal section (usually) 

External urethrotomy or 
perineal section. 



Dilatation (very rarely.) 
Internal urethrotomy 
Traumatic stricture. -{ (rarely.) 

Divulsion (rarely.) 
Perineal section (usually) 



Stricture complicated 
by retention. 



-< 



Relieve the retention and 
temporize if possible. Be- 
gin dilatation as early as 
practicable. 

Perineal section if opera- 
tion is urgently necessary. 



STRICTURE OF THE DEEP URETHRA. 



163 



5. Stricture complicated 
by retention. 



Divulsion as the opera- 
tion of necessity when no 
other means are at hand. 

Electrolysis i.e. galvanism 
as a temporary measure. 
This is to be followed by dil- 
atation or urethrotomy as 
occasion requires. 




"♦••£>— 



CHAPTER IX. 



THE SYSTEMATIC TREATMENT OF STRICTURE BY DILATATION. 

Instruments for dilatation of stricture. The instru- 
ments used for dilatation of stricture are of three vari- 
eties: (a) soft and flexible bougies, (b) fine, stiff, hair- 
like bougies known as filiforms, and (c) metallic sounds. 
Thesoftbougiesaremade in various patterns, the French 
and English varieties being those chiefly used. They 
are made in two forms, viz.: (a) with a plain conical point 
and (b) with an olivary tip. Their flexibility varies 
according to their composition. The best, or French 
bougies, are composed of a web of woven material cov- 
ered with rubber. The plain conical form is the most 
serviceable. The olive pointed variety is designed 
chiefly to avoid passing the instrument into any of the 
crypts or enlarged follicles which so frequently exist in 
chronic urethral disease. 

In selecting French bougies, it is best to choose 
those which are least flexible, as they are apt to be 
more durable and serviceable than the very flexible 
forms which are so limp that they bend upon them- 
selves when they come in contact with the slightest 
obstruction. The French bougies are unquestionably 
preferable to the English, but unfortunately they are 
not very durable. The latter variety is less flexible 
but much more durable. Filiform bougies — so-called 
because of their thread-like fineness — are composed of 
rubber, catgut, or whalebone. The whalebone variety 

is the best. The rubber variety is of the same COinpO- 
165 



i66 



STRICTURE OF THE URETHRA. 



1 



sition and construction as the ordinary French or Eng- 
lish bougies. 

Some forms of soft bougies are made with a small 
cap with a thread upon it, which may be fastened to a 
urethrotome or divulsor, the bougie acting as a guide 
or conductor for the larger instrument. Soft- 
bougies of considerable length may 
be procured when necessary to use 
them as guides for cutting or divul- 
sing instruments. The whalebone 
variety is stiffer and more durable 
than those composed of rubber, 
and if dipped in hot water, the 
point may be moulded into any 
form which may be deemed useful 
for the purpose of avoiding any 
diverticula that may exist in the 
urethra and prevent the engage- 
ment of the bougie in the orifice of 
the stricture. When used as a 
guide, a tunneled instrument may 
be passed over them. The late 
Professor W. H. Van Buren was 
the inventor of the first tunneled 
instruments which were used and 
should have due credit for them. In 
commenting upon filiform guides, 
Dr. Keyes gives the following time- 
ly words of advice.* 

i. The guide should be 18 



*1 ** 

Fig 52. 



screw g T^p P ed inches long; any cracked, bent, fis- Gouiey^s whaie- 

Guides. , r 1 • bone Guides. 

sured, or trayed out instrument 

should never be used. A short guide serves, but less well. 

2. In employing a whalebone as a guide, it should 

first be introduced into the bladder, then threaded into 

the instrument to be guided, and the latter pushed 

*Op. Cit. 



TREATMENT OF STRICTURE BY DILATATION. 



167 



gently down to the strictured point, while the whale- 
bone is held stationary at the meatus. If force be used 
here, the slender guide may be doubled up and a false 
passage may be made. All this may be avoided by 
gently and continously retracting the guide as the con- 
ducting instrument is passing the dangerous point and 
until it reaches the bladder. The length of the guide 
easily allows this to be done. 

3. The loop of the instrument to be conducted, 
should always be amply large and smooth in front so as 
to have a rounded and not a cutting edge, and if the 
movement of extracting the guide as the tunneled in- 
strument is being introduced cannot be performed as 
above described, both instruments should be withdrawn, 
for if the one be pushed forcibly, or the other pulled 
back, there is danger of cutting off a portion of the 
whalebone and leaving it in the canal, an accident 
which has occured in very competent hands." 

Dr. E. A. Banks, of New York, has devised some 
excellent whalebone bougies with filiform tips, as a sub- 
stitute for the combination of a filiform bougie and tun- 
neled sound. These are a most excellent device. 




Fjg. 54. Banks' Whalebone Bougies. 

Sir William Brodie is partial to the use of bougies 
composed of catgut, on account of the readiness with 
which they may be bent to conform to the curve of 
the urethra. These bougies are not only old fashioned 
and bunglesome, but they are not durable. 

Soft bougies and catheters are not so easily man- 
aged as stiff metallic instruments, as their flexibility 



1 68 



STRICTURE OF THE URETHRA. 



permits them to bend upon themselves when they come 
in contact with a tight stricture. It is difficult however, 
to produce injury with them, and inasmuch as instru- 
ments should be coaxed rather than forced through a 
stricture, their function in the treatment of strictures of 
small calibre is of great importance. 




Fig. 55. French Olivary Bougies. 

During warm weather gum instruments are apt to 
become soft and sticky; this may be prevented by dust- 
ing them with soap-stone. Care should be taken to have 
them perfectly free from oil before putting them away 
else they will become soft and worthless. They tend 
to grow brittle with age and it is not a difficult matter 
to break them. Care should consequently be taken to 
to guard against the use of superannuated instruments. 
In cleansing soft instruments strong solutions of car- 
bolic acid should be avoided, for if allowed to remain in 
such a solution for a few minutes, the polish is removed 
from their surfaces and they become rough, their facility 
of introduction being consequently impaired. 

Soft instruments maybe introduced with the patient 
in either the recumbent or standing posture, the latter 
being preferable. In practicing dilatation, soft instru- 
ments should be used whenever a smaller size than 16 
French is required. In cases of comparatively tight 
stricture in which instrumentation produces considera- 
ble pain and spasm, the use of soft instruments is abso- 
lutely essential until the urethra has been dilated to a 
moderate size, after which steel instruments may 
perhaps be substituted. 

Sounds are usually composed of inflexible metal, 
the steel instrument being the most popular. There 



TREATMENT OF STRICTURE BY DILATATION. 



169 



is an old fashioned variety composed of soft metal capa- 
ble of being bent in any form, the use of which is very 
limited. There are three principal varieties of sounds: 
The French variety or Benique sound has a double 
curve, the field of usefulness of which is very narrow. 
It is sometimes of service however, in cases in which 
for any reason we desire to allow a steel instrument to 
remain in the bladder for a considerable length of time. 
The extra curve is designed for adaptation to the form 
of the pendulous urethra in the flaccid condition of the 
penis. 

The most important features of the steel sound are the 
shape and length of its point. The English or Thompson 
instrument hasa pointthe diameter of which is but slight- 
ly less than that of the remainder of the canal, it being 
comparatively blunt. The curve is rather long and the 
point is at right angles with the shaft. Van Buren de- 
vised a modification of the English instrument which is 
very popular among American surgeons. The point of 
this instrument is smaller, more conical, and the curve 
shorter than that of the English instrument. The Van 




Fig. 56. Van Buren's Steel Sound. 



Buren sound is advantageous on account of its short curve, 
the form being such as to make the instrument easily 
controlled by the hand. There is a compensatory 
disadvantage in the fact that the point is so small and 
conical, that injury at the hands of a careless operator, 
might be produced by it more readily than by the En- 
glish instrument. As the sound acts somewhat on the 
principle of a wedge, it is obvious that stretching the 
stricture is more likely to be forced by the American 
than by the English instrument. 



I70 STRICTURE OF THE URETHRA. 

Care should be taken that the sounds are per- 
fectly clean, i. e. aseptic, before their introduction into 
the canal. Should they become rough they should be 
thrown aside or polished anew. 

It is desirable for the surgeon to have a second set 
of sounds with a very short curve and conical point, for 
use in the pendulous urethra. In the majority of cases 
of stricture it is not necessary to pass an instrument 
completely into the bladder, in order to secure the max- 
imum of beneficial effects from the dilatation. Pros- 
tatic and vesical irritation, are very often caused by 
the mechanical injury produced by sounds introduced 
into the urethra, for the purpose of treatment of a stric- 
ture located several inches anterior to the neck of the 
bladder. There are several varieties of sounds with a 
very short curve, in the market. Messrs. Truax, Greene 
& Company have constructed a ! set for my use, the shaft 
of which is rather shorter than any which I have seen. 
It is advisable not to have the point of such an instru- 
ment too tapering, or it will be necessary to introduce 
it farther into the urethra than is necessary before its 
greatest diameter is brought to bear upon the stricture. 
The proper curve for metallic instruments, as already 
stated, is that known as the Thompson curve. This 
corresponds to the curve of a circle 3^ inches in 
diameter. The proper length of arc of such a circle 
for the beak of sounds is that subtended by a chord 2% 
inches long. A shorter curve however is most useful 
as enabling the operator to keep the instrument under 
better control. 

Continuous dilatation is of service in certain cases 
of tight stricture in which instrumentation is exceed- 
ingly difficult. In cases of this kind, considerable nicety 
of judgment is required regarding the advisability of 
withdrawing an instrument when once it has entered 
the bladder. The practice of continuous dilatation is 
certainly tempting under such circumstances, and the 



CONTINUOUS DILATATION. I 7 I 

surgeon is certainly excusable for hesitancy in deciding 
to remove an instrument which perhaps required the 
utmost patience and perseverence for its introduction, 
providing there exists, any possibility of benefit resulting 
if it were allowed to remain. It is usually perfectly safe 
to permit a small soft or filiform bougie to remain in 
the urethra after it has passed the stricture, and as a 
rule, the effect is beneficial, for in a short time it will be 
found that more or less absorption has occurred and 
the bougie which was previously tightly grasped has 
become loosened, after which it may be removed and 
an instrument of a larger size introduced. 

The first instrument that is passed should be tied 
in the bladder and allowed to remain in situ for from 
12 to 24 hours, during which time the urine may escape 
beside it; it certainly will do so at the end of that 
time. When the first instrument is removed, the next 
larger size should be immediately introduced, as a cer- 
tain degree of re-contraction may occur in a few min- 
utes and prevent the introduction of another instru- 
ment. A certain amount of urethritis is caused by the 
presence of the bougie, but this is rarely severe and 
will subside very soon after gradual dilatation has been 
substituted for the continuous method. Continuous 
dilatation should be practiced until a No. 10 or 12 French 
can be introduced, after which gradual dilatation should 
be instituted. Where it is practicable to do so, a ver} 7 
small catheter may be passed instead of a bougie, to 
facilitate evacuation of the bladder in case retention 
should occur. At the second passage of instruments as 
a rule, a small catheter or bougie may be introduced, 
even though at the first operation it may have been dif- 
ficult to pass even a filiform bougie. 

The principal objection to the use of the method 
of continuous dilatation, is the tendency to the devel- 
opment of inflammation of the bladder. This may be 
obviated by daily irrigations of the viscus with a mild, 



172 STRICTURE OF THE URETHRA. 

warm antiseptic solution. Sloughing of the urethral 
mucous membrane with perineal abscess and fistula has 
been known to occur as a result of this method of treat- 
ment. Erichsen records a case of this kind. Such an 
accident could only occur as a result of too extreme 
distention, by forcibly introducing an instrument larger 
than is necessary. It is wise to practice this method in 
all cases complicated by retention, as soon as an instru- 
ment can be passed through the stricture. 

Gradual dilatation is generally the most applicable 
method of treatment of stricture. It should be begun 
on about the third day after a preliminary exploration 
has determined the precise location of the stricture or 
strictures, and the various qualities of the lesion to which 
allusion has already been made. It may be necessary 
to vary the interval following the preliminary explora- 
tion according to the amount of reaction from the 
latter. Much depends upon the tolerance of the 
urethra for instrumental interference, and upon the ner- 
vous susceptibility of the patient. If a preliminary 
meatotomy has been performed, it is often well to wait 
until the meatus has completely healed before going on 
with the treatment of the deeper portions of the canal, 
unless the necessity for dilatation is urgent, as in very 
tight strictures in which retention may occur at any 
time. The irritation of the raw cut surface produced 
by the passage of the sound over it, invariably gives 
rise to a certain amount of reflex spasm of the deeper 
parts of the urethra. As a consequence of this spasm, 
much irritation and inflammation of the stricture may 
be produced by passing a comparatively small sized 
instrument. 

If it be determined to treat the stricture by gradual 
dilatation, the treatment should be begun with the 
insertion of a small sound at the sitting next following 
the preliminary exploration, or as soon as the meatus 
has healed, as the case may be. The first instrument 



GRADUAL DILATATION. I 73 

passed should be small enough to be introduced with- 
out any difficulty. In this way the sensibility of the 
stricture may be to a certain extent blunted and the 
canal opened up, thus facilitating the passage of an in- 
strument of sufficient size to distend the stricture. 
After the withdrawal of the small instrument, a second 
should be inserted which is large enough to distend the 
stricture, but which at the same time, does not require 
force for its introduction. If pain and spasm are ex- 
cited the sound should be immediately withdrawn. If 
however, the urethra tolerates its presence, it should be 
allowed to remain for a minute or two to secure the 
full effects of the distention which it produces. It 
should now be removed and the next larger size intro- 
duced in the same manner. It is rarely advisable to 
use more than two, or at most three sounds, at a single 
operation, a single instrument being best if the stricture 
be very irritable. If the surgeon undertakes to hurry 
the matter he may produce severe urethritis, prostatitis, 
cystitis, epididymitis, or urethral fever, or may cause 
a perfectly tractable stricture to become irritable and 
resilient. Any of the accidents which have been men- 
tioned may prove a serious complication, and in addi- 
tion will inevitably delay the treatment. It is my opin- 
ion that the surgeon is quite often responsible for con- 
gestion and inflammation, irritability and resiliency of 
stricture occurring in the course of treatment by dila- 
tation. One of the cardinal principles which should 
guide the operator is the avoidance of force, conjoined 
with efforts to coax the stricture, so to speak, to a cure. 
Nothing is gained by torturing the sensitive tissues of 
the lesion by the introduction of too large and too many 
instruments. 

The preliminary administration of anodynes, the 
continuous use of nervous sedatives and antispasmodics, 
and if necessary anaesthetics, are frequently useful ad- 
juncts to treatment by dilatation. The usefulness of 



174 STRICTURE OF THE URETHRA. 

measures of this character is well illustrated by a case 
which is at present in my hands. 

The patient is of a highly irritable nervous temper- 
ament, very sensitive, and dreads each operation of dila- 
tation. I have been attempting for a long time to treat 
the case with metallic instruments, but until recently 
have been unable to introduce them without using more 
force than I consider advisable. The obstruction ap- 
peared to be due to severe spasm of the deep urethra. 
So severe was the spasm all along the canal that even 
the penile portion of the urethra contracted down so 
tightly about the instrument that some little force was 
necessary in its withdrawal. Within the last two or 
three weeks I have given the patient liberal doses of 
bromide of potassium and ergot, and have instructed 
him to take one-fourth of a grain of morphia one hour 
before visiting me. Much to my gratification, I have 
had no trouble in introducing steel instruments in in- 
creasing sizes, since the first occasion on which the 
morphia was taken. 

The sudden acquirement of a spasmodic element 
in a stricture which is under treatment may indicate 
renal complication. In one of my own cases the forma- 
tion of a peri-nephritic abscess, was heralded by severe 
spasm of a stricture then under treatment by dilata- 
tion. 

At the next sitting, dilatation should be begun with 
an instrument a size smaller than the largest which was 
introduced at the previous operation. Should the 
urethra be very irritable it may be necessary to again 
pass as a preliminary measure a very small instrument 
for the purpose of blunting sensibility. Two sizes 
should be introduced as before. 

The frequency of operations of dilatation should 
vary according to the exigencies of each particular case. 

The majority of surgeons in their enthusiasm for a 
speedy cure of the stricture neglect to study the case 



GRADUAL DILATATION. 1 75 

carefully, and consequently introduce instruments too 
frequently. It is not an unusual experience for me to 
meet with cases which have been tortured into irrita- 
bility and resiliency, by the daily introduction of sounds 
at the hands of over-enthusiastic operators. While it 
is permissible in very tight strictures, to introduce soft in- 
struments every day, it is rarely beneficial and usually in- 
jurious to pass steel instruments oftener than once in three 
days. In the majority of cases once in four or five days or 
even longer is sufficiently often. 

Some patients will complain greatly of pain, and 
severe spasm with perhaps urethral chill and fever will 
result if the sound be introduced oftener than once a 
week. Quite prolonged intervals of rest are essential 
in some cases. I have met with cases in which I had 
formed the opinion that a radical operation was neces- 
sary, as a consequence of irritability and resiliency of 
the stricture, but when the patient has returned to me 
after an absence of several weeks I have been gratified 
to discover that the stricture could be dilated quite 
readily. The indications in such cases are very plain 
and should receive due consideration. 

It is necessary in all cases of tight stricture to begin 
the treatment with soft instruments and perhaps by the 
method of continuous dilatation. After the stricture 
has been dilated to the calibre of from 10 to 12 French, 
steel instruments may be substituted. With steel in- 
struments of small size there is great danger of produc- 
ing injury. Such instruments do not pass of their own 
weight, but require a little force. The degree of pres- 
sure exerted requires some nicety of judgment, as it 
takes but little force to drive the point of a metallic in- 
strument through the urethra, thus causing a false pas- 
sage. In some instances it may be necessary to use soft 
instruments up to a considerable size before substitut- 
ing sounds. 

Dilatation acts in two ways: in the first instance, 



I76 STRICTURE OF THE URETHRA. 

the sound produces stretching of the stricture and tem- 
porarily increases its calibre. The next effect is the 
production of absorption of the adventitious tissue. In 
order for absorption to occur, it is necessary that a cer- 
tain amount of reaction should follow the introduction 
of the sound. It is upon the increase of the nutrition 
of the part, incidental to the slight hyperaemia which 
results from the mechanical stretching of the stricture, 
that the cure of the lesion depends. This reaction must 
be kept within bounds, for when it approximates 
marked inflammation, the condition can only be aggra- 
vated by sounding. A slight increase in discharge fol- 
lowing the use of the sound is usual; a marked increase 
is an indication that undue inflammation has been ex- 
cited, and should serve as a caution against further 
attempts at dilatation until the parts have had time to 
recover. 

For a short time after the introduction of the sound 
the flow of urine is facilitated on account of the mere 
mechanical stretching which the instrument has pro- 
duced. This enlargement of the calibre of the stric- 
ture persists for from 24 to 36 hours, at the end of which 
time reaction occurs, with coincident hyperaemia of the 
diseased tissues and an increased activity of the pro- 
cesses of nutrition. A moderate amount of swelling 
results which serves to diminish the calibre of the stric- 
ture. Within a day or so however, absorption begins 
and continues for several days, at the end of which time 
re-contraction commences. If a sound be introduced 
during the time the reaction is at its height, actual in- 
flammation is excited and the case is made much 
worse. 

As the reaction produced by the sound diminishes, 
the benefits of the absorption are apparent in the in- 
creased size of the stream. If the operation has 
proved successful, the stream of urine will be larger 
than before the introduction of the instrument. The 



TREATMENT OF STRICTURE BY DILATATION. 



177 



rapidity with which reaction comes on, and its degree, 
and the amount and duration of the absorption vary 
greatly in different cases. A careful study of each par- 
ticular case, teaches the surgeon when another opera- 



INSTRUMENTS FOR EXPLORATION AND MEDICATION 
OF THE URETHRAL MUCOUS MEMBRANE. 




Fig. 58. 
Otis' Endo- 
scopic Tube. 



O 




Fig 58. 

Brown's Urethral 

Speculum, 



Fig. 60. 
Klotz's Endoscope. 



Fig. 61. 
Weir's Meatoscopt 



tion is desirable. If the canal be dilated in a routine 
manner and increasing degree every three or four days 
— more or less — many disappointments will be exper- 
ienced. Each case is a lazv tcnto itself and should be 
treated ttpon its own merits. In some cases the urethra 



i 7 8 



STRICTURE OF THE URETHRA. 



will not tolerate any increase of the size of the instru- 
ment for several successive operations, it being neces- 
sary to introduce the same instrument several times. 

The introduction of the sound usually occasions 
more or less smarting and a variable degree of pain, 
which is most marked as the point of the instrument 
approaches the neck of the bladder. As it passes over 




Fig. 57. Method oi Injecting the Deep Urethra.— {After Finger.) 



this highly sensitive portion of the canal more or less 
nausea and faintness may be produced; actual syncope 
not infrequently results. As already asserted, the patient 
should never be operated upon for the first few times in 
a standing posture, although it may be found to be more 
advantageous than the recumbent posture later on. A 
semi-recumbent position is perhaps most universally ap- 
plicable. Care should be taken that the instrument is well 




Showing Granular Urethritis. {After Finger.) 



TREATMENT OF STRICTURE BY DILATATION. 1 79 

warmed and lubricated before its introduction, else pain 
and spasm will be greatly enhanced. The best lubricant 
is albolene with the bichloride of mercury, i in 1,000, in 
combination with 5 or 10 grains of cocaine to the ounce. 
Should medicated applications to the canal be required 
after removal of the sound, for the purpose of curing a 
refractory gleet, glycerine should be used for the pur- 
pose of lubricating instruments. Oils coat the surface 
of the mucous membrane and prevent the proper action 
of astringent remedies applied by the endoscope or long 
urethral syringe. 

Medication is often necessary during treatment by 
dilatation or after the stricture has apparently been 
removed by dilatation or cutting. The cure of a stric- 
ture is often only a necessary preliminary to the local 
treatment of an obstinate gleet. The accompanying 
illustration (Plate 5 ) shows the peculiar granular state 
of the mucous membrane which frequently attends 
urethral stricture. Obviously, the cure of the stricture 
alone is not sufficient to cure the morbid state of the 
canal. Instillations of the nitrate of silver, five to 
twenty grains to the ounce, are most valuable in curing 
this state of affairs. The illustration shows the futility 
of attempting to cure a gleet by urethrotomy alone, in 
cases complicated by granular urethritis. Posterior ure- 
thritis is often a cause of the perpetuation of gleet after 
the cure of stricture, and requires very careful treat- 
ment by deep instillations of antiseptics and astringents. 

The endoscope is of great value in the diagnosis 
and treatment of morbid states of the urethral mucous 
membrane complicating stricture. The use of the 
deep urethral syringe is often invaluable as an adjuvant 
to dilatation. 



CHAPTER X. 



UNTOWARD EFFECTS OF DILATATION. 

URETHRAL FEVER — HAEMORRHAGE — FALSE PASSAGES — 

ACUTE INFLAMMATION OF THE URETHRA, BLADDER 

AND EPIDIDYMIS. 

Urethral or Urine Fever is an omnibus term applied 
to certain morbid phenomena which occasionally follow 
operations upon the genito urinary tract. These phe- 
nomena frequently follow simple dilatation, indeed a 
slight operation is often productive of serious results, in 
cases in which severe operations are well borne. 

The greatest discrepancy exists in the statements of 
various authorities regarding the pathology of the poly- 
morphous disturbances known by the various terms of 
urethral, urinary, (Guyon) and urine fever. This I firmly 
believe to be due to the fact that these terms are ap- 
plied in a hap-hazard manner to several distinct types 
of disease consequent upon diseases of, and operations 
upon, the genito-urinary apparatus; and I am positive 
that a careful survey of the clinical evidence upon the 
subject will bear me out in this opinion. Urethral fever, 
as the term is ordinarily used, is, so to speak, a blanket 
term as broad as the mantle of charity, which comprises 
a series of widely varying phenomena following chronic 
disease, or accidental or surgical trauma of the genito- 
urinary tract. Fallacious as the nomenclature of these 
phenomena may seem to be, we are compelled to select 
some comprehensive term by which they may be recog- 
nized. The term tirine fever as suggested by Reginald 

180 



URETHRAL FEVER. l8l 

Harrison is perhaps the most accurate.* Unfortun- 
ately, however, even this term is suggestive only of one 
element which may act as a causal factor in the produc- 
tion of the morbid phenomena which we are about to 
consider. Harrison has adopted this term because of 
his opinion that the so-called urethral fever is invariably 
due to morbid changes in the urine at the site of injury, 
these morbid changes giving rise to the development of 
toxic materials, which, when absorbed into the circulation 
are always inimical to health and often prodttctive of a 
fatal result. Whatever the cause or causes of urethral 
fever may be — and this we will consider later on — the 
subject is one of the greatest practical importance to 
the surgeon, for the various phases of this complex affec- 
tion constitute the principal danger of operations or 
injuries of the urethra, prostate and bladder. 

It should be apparent to the clinician that the om- 
nibus term urethral fever, has been made to include 
conditions which bear no relation to each other, save 
in the fact that they have the same point of departure, 
viz., disease or injury of the genito-urinary tract. It is 
obvious that nothing else justifies the prevalent nomen- 
clature of the various phenomena resulting from opera- 
tive interference with this region. Surgical shock, 
uraemia, nervous manifestations and sepsis following 
operations on the urethra and bladder, are entirely dif- 
ferent conditions. It is true that these various states 
may exist in varying combinations, this does not how- 
ever justify an omnibus nomenclature. How widely 
different are those cases in which death results shortly 
after the introduction of a sound, and cases of classical 
septaemia following genito-urinary operations; yet these 
distinctive types of disease are included under the head 
of urethral fever. Much of our recent knowledge of 
the subject is due to bacteriological studies, which prove 
conclusively that many of the cases hitherto described 

*Lettsomian Lectures, 1888. 



1 82 STRICTURE OF THE URETHRA. 

as classical urethral fever, are due to germ infection, or 
the absorption of germ products, and should be desig- 
nated accordingly. 

From an etiological standpoint, I believe that we 
are warranted in dividing so-called urethral fever into 
6 forms of morbid phenomena, these varieties, however, 
being capable of demonstration only in typical cases in 
each instance. They may merge one into the other and 
are all secondary to genito-urinary operations, chronic 
disease, or injury. 

i. The first form, which is by far the simplest, con- 
sists of a nervous rigor, which is not succeeded by fever, 
and which follows within a comparatively short time, 
operations or injury. This nervous disturbance is, in 
all probability, due to slight surgical shock, with a re- 
sultant vaso-motor disturbance of the peripheral circu- 
lation. 

2. Traumatic or surgical fever (ferment fever) , due 
to the same causes, and dependent upon excessive re- 
action from surgical shock — perverted metabolism — in 
combination with decomposition of fibrin ferments. 
This form of fever is quite apt to be modified by a 
varying degree of septic infection. 

3. Toxiccemia following severe shock with a result- 
ant perverted elaboration of the urinary secretion and 
the formation of organic poisons similar to the vegeta- 
ble alkaloids. Associated with this we have reflex in- 
hibition of the function of the kidney with its attend- 
ant uraemia, and a perversion of general tissue metabo- 
lism. This we may term the typical form of urethral 
fever. It is sometimes complicated by convulsions. 

4. Classical septaemia, which may prove fatal 
within a short time, or may merge into the pyogenic 
condition known as pyaemia, with its characteristic cir- 
cumscribed and diffuse suppurations in the various 
organs and tissues of the body. The latter may super- 



URETHRAL FEVER. 1 83 

vene without the characteristic phenomena of ordinary 
sepsis. 

5. Chronic urinary fever attendant upon obstruc- 
tive diseases of the urinary organs. 

6. Cases of mixed type which combine in varying 
degrees elements of the first four forms of the disease. 

If the above classification be scientifically correct, 
it is not surprising that the opinions of various author- 
ities in regard to the pathology of urethral fever vary 
so widely. There must be some explanation for the 
fact that one authority claims that these varying phe- 
nomena are invariably septic ; another that they are 
due to ammoniacal decomposition of urine and subse- 
quent absorption of the products; another that they are 
due to simple uraemia, and last, but not least — and of 
this theory Reginald Harrison is the principal exponent 
— that they are due to obscure changes in the urinary 
secretion, and the formation of new and as yet uniso- 
lated toxic compounds. It is evident to every practical 
surgeon that none of these causes are sufficient to explain 
all of the cases of so-called urethral fever. Simple ab- 
sorption of healthy urine certainly will not cause the 
disease, nor, as has been shown by Dr. Keyes,* will it 
produce even simple suppuration when introduced into 
the cellular tissue by hypodermic injection. We do 
know however, that urine in a state of decomposition, 
is possessed of most powerful propensities for evil — in 
fact, there is hardly any organic substance with which I 
am acquainted that is so inimical to the vitality of cel- 
lular tissue. The experience of our most eminent sur- 
geons in cases of urinary extravasation will bear me 
out in this assertion. Now, there is a close resemblance 
between the effects of extravasation of decomposing 
urine and those of the poisons of erysipelas, of dissect- 
ing wounds, or even the bite of venomous reptiles, as 
far as their effects upon the vitality of connective tissue 

*Op. cit. 



184 STRICTURE OF THE URETHRA. 

are concerned. It is obvious to anyone who stops to 
consider for a moment, that there must necessarily be 
in all cases of injury or operations upon the urinary 
organs, pronounced danger of septic infection. The 
injury, or the site of the injury, is usually such that free 
drainage is impossible; decomposing urine is usually 
present, and is productive of more or less wide-spread 
death of connective and cellular tissue, and there always 
prevail the conditions of heat and moisture. Such an 
environment, as every biologist is well aware, is peculiarly 
favorable to the development of those minute organisms 
upon which septcemia and its congeners unquestionably 
depend. 

None of the explanations which have been given 
will, when taken alone, explain the fatal result which 
has been known to occur from the simple introduction 
of a smooth staff into the urethra. 

There is also food for reflection in the fact that 
a simple straight cut in the urethra — as, for instance, that 
produced in internal urethrotomy — is productive of less 
shock in many cases than repeated stretching of the sensi- 
tive structures of the stricture by a sound or bougie. It is 
well known that an irritable, sensitive, and contractured 
tissue is much more safely and comfortably dealt with 
in any situation by complete division than by repeated 
attempts at stretching. 

The cure of stricture by gradual dilatation is depend- 
ent upon (1) mere mechanical distension; (2) upon re- 
actionary hyperemia, with increased tissue change at 
the site of the organic deposit. The functions of the 
lymphatics and veins are increased in activity, and ab- 
sorption takes place very rapidly. It would appear, 
then, that if the tissue be extraordinarily sensitive, as 
is frequently the case in organic stricture, and if there 
be present toxic principles from decomposing urine, or 
ordinary septic materials at the site of the stricture or 
behind it, the operation of dilatation must necessarily 



URETHRAL FEVER. 1 85 

be followed by a degree of nervous shock dependent 
upon the susceptibility of the individual and the degree 
of roughness of manipulation, and by a varying degree 
of absorption of noxious materials. The lymphatics 
and veins, unfortunately, have not the power of dis- 
criminating between those organic substances which are 
inimical to the welfare of the individual, and those 
which can be disposed of in a physiological manner 
without injury to the blood or tissues, and they therefore 
take tip the poisonous materials simultaneously with the 
products of retrograde tissue change. 

The relation of organic and functional disturbance 
of the kidneys to so-called urethral fever is a most in- 
timate one. There is probably no case of long stand- 
ing obstructive disease of the genito-urinary tract, which 
is unaccompanied by functional aberration of the kid- 
neys, and in a large proportion of cases there occurs 
later on actual organic changes in the renal tissues. 
This condition of affairs is to be anticipated and should 
be given serious consideration in every case of chronic 
urinary disease. The immediate effects of the kidney 
difficulty may not be marked, because of the activity of 
vicarious elimination by the skin and bowels — this vi- 
carious action of these structures constituting the means 
by which the system accommodates itself to the imper- 
fect elimination of the constituents of urine. There 
are very few persons, even among those who term them- 
selves healthy, in whom the bodily sewage is absolutely 
perfect, and it is obvious that when the kidneys perform 
their functions imperfectly, this condition of imperfect 
sewage becomes one of vital importance. When, as a 
consequence of operations upon the genito-urinary 
organs, surgical shock is produced, reflex hyperemia of 
the renal tissue is quite apt to result. This causes a 
strain upon the circulation of the kidney, which in its 
impaired condition it is unable to withstand, and as a 



1 86 STRICTURE OF THE URETHRA. 

consequence its functions are completely inhibited with 
resultant uraemia. 

To those who are familiar with the physiology of 
the nervous system in its more intimate relations to 
visceral functions, the association of renal aberration 
and reflex irritation is not at all novel, but there are 
many who have never had this particular phase of 
neuro-pathology brought prominently before them. 
Many interesting examples of urinary suppression from 
reflex inhibition of renal function have been observed. 
My friend Dr. J. W. Long, of Randleman, South Caro- 
lina, in an exceedingly able and scientific paper on this 
subject before the Southern Surgical and Gynaecological 
Association, reported a case which is of great interest.* 
"H, age seven years, complained of pain and soreness 
in the ileo-caecal region, had some fever, and was con- 
fined to bed. There was complete suppression of urine 
for three days, the catheter being repeatedly used with- 
out getting any urine. Appendicitis was diagnosed and 
preparations for an operation made. Some delay oc- 
curring,the father, without my knowledge, gave one tea- 
spoonful of a vermifuge which contains Jerusalem oak; 
the next morning the boy passed at stool a ball of lum- 
bricoid worms which the father untangled and found to 
contain sixty of these parasites. Within twelve hours 
after discharging the worms, the boy passed unaided 
six or eight quarts of urine. He speedily convalesced." 
Dr. Long's remarks anent cases of this character are of 
especial value, and his paper will well repay careful study. 

Peyrani has shown that the sympathetic nerves 
have a remarkable influence over the secretion of urine, 
galvanization of these nerves increasing the amount of 
urine and urea, while section of them causes both urine 
and urea to sink to a minimum. f 

Bernard long ago proved that albuminuria can be 

*Trans. Southern Surgical and Gynaecological Assoc. 1891. 

t" Flint's Physiology of Man." vol. iii Secretion, p, 281 et seq, 



URETHRAL FEVER. I 8/ 

produced by puncture of a certain spot in the floor of 
the fourth ventricle.* 

Edes remarks: "Lesion of the cerebral peduncles, 
section, destruction, or irritation of the spinal cord, and 
irritation of the renal nerves, are also causes of albumi- 
nuria." f 

Millard calls attention to an interesting paper by 
Drs. Arnand and Butte on "Neuropathic Albuminuria," 
presented to the Parisian Academy, and directs especial 
attention to the description of a type of albuminuria 
"characterized by pre-existing and existing symptoms 
in the viscera innervated by the pneumogastric nerve. 
The irritation to the pneumogastric in these viscera, is 
reflected through the vaso-motor system to the kidneys, 
causing albuminuria." J 

There is only too abundant proof of the dependence 
of renal disturbances — and especially albuminuria — upon 
reflex irritation. As Dr. Long states in his excellent 
paper, renal aberration is most liable to occur from 
operations in and about certain special regions — 
notably the abdomen and genito-urinary organs. The 
explanation of this fact is not very difficult; to the neuro- 
physiologist. The intimate relation of the sympathetic 
ganglia through their visceral filaments of distribution 
and their liberality of innervation of the genito-urinary 
organs, with the nervous supply of these regions, is an 
all-sufficient explanation. Nowhere are the cerebro- 
spinal and sympathetic systems more closely associated 
than in these parts. This being understood, it is by no 
means surprising that injuries in these locations should 
give rise to reflex disturbances of co-related parts, even 
though the latter may be more or less distant. The 
functions and physiological integrity of the abdominal 
and pelvic viscera are dominated by the solar plexus — 
so aptly termed the abdominal brain — the kidneys being 

*i. Flint, Physiology of Man, vol. m, Secretion, page 281 et seq. 
2. fPepper's System of Medicine, vol. iv, p. 4o. 
3 " JN. Y. Medical Journal, May 9, i89i. 



1 88 STRICTURE OF THE URETHRA. 

intimately associated with the other organs through the 
medium of the renal plexus; the component parts of 
which are filaments from the solar and aortic plexuses, 
semilunar ganglia, and lesser splanchnic nerves. Pass- 
ing into the renal substance from the renal plexus, are 
some fifteen or twenty filaments with numerous asso- 
ciated ganglia. These nerve filaments accompany the 
arteries. The multitudinous distribution of these 
filaments to the parenchyma and vascular system of the 
kidneys is well described by Holbrook.* As described 
by this author, the nerves supplying the renal tissue are 
principally of the non-medullated variety, sometimes 
surrounding the arteries in immense numbers, encircling 
them around, above and below, freely branching, 
bifurcating and supplying all of the neighboring struc- 
ture with numerous delicate fibrillse; a plexus encircling 
every tubule: supplying the connective tissue extending 
into the layer known as the membrana propria, and 
even piercing this structure and penetrating into the 
epithelia and the cement substance between them; the 
nerves also give off delicate ramifications of fibres to 
the afferent blood vessels by which they enter the tufts 
and produce a delicate plexus spun around the 
capillaries. The distribution of nerves is richer in the 
convoluted and narrow than in the straight collecting 
tubes. Reasoning from these anatomical facts, it is not 
difficult to understand how irritations of the abdominal 
and pelvic viscera or of the genito-urinary organs, may 
be reflected to, and produce morbific changes in the 
kidneys. Hardly a case of genito-urinary disease per- 
haps, runs its course without some such reflex im- 
pression. The result depends chiefly upon the organic 
state of the kidneys; if this be bad, speedy death may 
result. To use a homely illustration of this point, all 
operative manipulations of the genito-urinary tract are 

* Paper on nerve terminations in the kidneys, before the Am. Soc. of Microsco- 
Dists. Quoted by Millard. Dis. of the Kidneys. 



URETHRAL FEVER. 1 89 

liable to concuss, so to speak, the renal nerve supply, i. 
e. are likely to bring a reflex strain upon the vascular 
supply, and secondarily upon the nutrition of the kid- 
neys. 

Regarding reflex impressions upon the structure 
and functions of the kidney, Engelmann says:* "Func- 
tional derangement, and finally, morbid changes, are 
produced by nervous influences emanating from dis- 
eased pelvic viscera. (1) As reflex phenomena or (2) 
by perverted nerve action by the secretory nerves due 
to the intimate connection of the uterine and renal 
plexus. Suppression of urine occurs as a reflex: more 
generally speaking, hysterical symptom, and may lead to 
pyelitis, a mild nephritis, or hydronephrosis." (?) Dr. 
Engelmann then cites a case in which nephritis followed 
spasmodic stricture of the urethra, (?) after which he 
says, " I believe such cases to be more frequent in con- 
nection with pelvic disease than we may suppose, as the 
slight symptoms prodnced are overlooked amid the 
varying pains of the primary disease." Obviously, what 
is true of pelvic and utero-ovarian lesions in women, 
is equally true of genito-urinary lesions in the male, as 
far as reflex functional and structural aberration of the 
kidney is concerned; 

As regards renal disturbances after laparotomy, it 
has been fully established by English and others, that 
abdominal traumatisms are prone as a result of an im- 
pression made upon the solar plexus, to develop 
albuminuria. Weir relates a case of gastro-enterostomy, 
done for simple pyloric stenosis, as illustrative of the 
occasional effects of abdominal operations upon the 
kidney. Prior to the operation repeated examination 
failed to show the presence of either albumen or sugar, 
but within forty-eight hours after the operation one-half 
per cent, of albumen and four per cent, of sugar, with 
granular and epithelial casts, were found in the urine. 

*Trans. Am, Gyn. Society 1889. 



I90 STRICTURE OF THE URETHRA. 

Forty-eight hours later the morbid state of the 
urine had entirely disappeared. Weir seems to believe 
that some traumatic disturbance of the solar plexus 
during the operation explains the renal symptoms. 

I trust that the foregoing rather voluminous ex- 
patiation upon the relation of reflex irritation to renal 
aberrations, may 'not seem superfluous, for to me it has 
a most important practical bearing upon so-called uri- 
nary fever, and the various accidents embraced under 
this omnibus term which are the bete noir of genito- 
urinary surgery. 

The subject of autogenesis in its relations to the de- 
velopment of certain constitutional diseases demands more 
attention than is usually accorded it, and it is probable 
that physio-chemical researches in this direction, will in 
the future shed new light upon many diseases, the eti- 
ology of which is now obscure. Among the modern 
writers who have given considerable attention to the 
morbid results of perverted physiological chemistry, 
Benjamin Ward Richardson is perhaps the most prom- 
inent. It is to the researches of this author that we are 
indebted for the most widely accepted theory of the 
pathology of rheumatism. It is probable that perverted 
tissue metabolism bears a causal relation to the typical cases 
of tire thral fever. This perverted physio-chemism may 
quite readily be brought about by surgical shock, this 
being especially marked in the glandular tissues. We 
know quite well that mental emotions of various kinds 
and those impressions upon the nervous system which 
result in the condition that we term ''shock" may pro- 
duce marked changes in the physiological secretions of 
the body, these changes consisting either in an increased 
or diminished flow, or obscure chemical changes of com- 
position; thus we may have through various nervous 
impressions an increase or decrease in the quantity of 
the saliva, the lacteal secretion, the gastro-intestinal 
secretions, the urine and of the menstrual flow. 



URETHRAL FEVER. IQI 

A familiar illustration of the chemical effect of 
various emotions upon physiological secretions, is the 
change in the quality of the lacteal secretion, induced 
by fright, anger or grief. This change, although occult 
and incapable of demonstration by microscopical or 
chemical research, is most pronounced in its morbid 
effects upon the child; cholera infantum of a most fatal 
character being a frequent sequel to the emotion of 
anger in the mother. Precisely what this change in chem- 
ical composition may be is an open question, but it is possi- 
bly a species of decomposition which results in the forma- 
tion of a poison analagous to the " tyrotoxicori' discovered 
by Prof. Vaughn in impure cow ' s milk. It is well known 
that great care is necessary on the part of those who 
supply milk for the use of infants, to prevent fatigue 
and various sources of excitement in the cows from 
which it is taken. It is well known, too, that sexual ex- 
citement in the cow is productive of marked changes in 
the milk, and renders it unfit for human food. 

If the changes above indicated occur in one se- 
cretion, it is highly probable that all of the physiologi- 
cal secretions are susceptible to them. It is probably 
true in the case of the saliva, that the emotion of anger 
causes the development of toxic principles in that se- 
cretion, and this may possibly explain the serious results 
that are so apt to ensue from the bite of an enraged 
human being. 

The difficulty of proving this theory in the present 
state of our knowledge of physiological chemistry, is 
obvious. In the case of the urine the influence of sur- 
gical shock may be inferred to consist in the develop- 
ment of organic poison in that secretion. This may be 
considered to be hypothetically analogous to the 
ptomaines and leucomaines discovered by Selmi and 
Gautier in both dead and living bodies, and which so 
closely resemble the vegetable alkaloids, particularly 



1 92 STRICTURE OF THE URETHRA. 

nicotine, brucin and strychnine.* The toxicaemia re- 
sulting from such changes will perhaps explain the oth- 
erwise obscure and mysterious cases of death following 
the simple introduction of a sound. 

In some cases the development of uraemia or toxi- 
caemia is very gradual, and results from successive oper- 
ations upon the urethra. The poisonous materials may 
accumulate in the system for some time and their presence 
fail to manifest itself until the system, so to speak, is ready 
for the explosion, when a previously well tolerated and 
comparatively slight irritation of the genito-urinary 
apparatus will be sufficient to develop a serious result. f 

The following case illustrates the point just made : 
A competent surgeon of this city had performed ure- 
throtomy upon an apparently healthy young man of 28 
years of age. The stricture was located about three- 
fourths of an inch posterior to the meatus and was 
divided under cocaine without any difficulty or pain 
whatever, each subsequent operation of dilatation 
being preceded by the injection of a four per 
centum solution of the muriate of cocaine, the quan- 
tity used being about two fluid drachms. About 
a week after the urethrotomy, the patient com- 
plained of considerable nervousness and insomnia, 
but this was not considered of any particular 
importance. On the 9th day an attempt was made to 
perform the usual operation of sounding and injection 
of cocaine, the patient meanwhile lying on an ordinary 
surgical chair. The doctor left the patient for a moment 
to obtain his sound and to give the cocaine an oppor- 
tunity to affect the urethra. He was called back in 
about a minute by the patient, who complained of diz- 
ziness, and immediately fell back in the chair in con- 
vulsions. Assistance was called, stimulants were given, 

*Harrison believes that such compounds may develop in the urine, under certain circ- 
cumstances. R. Harrison, Op. cit. 

tSir Andrew Clark has also recently suggested that "catheter fever" may be due to 
some nutritive disturbance due to reflex nervous influences. Meeting of Bri... Med. 
Ass'n. Aug. 1888. 



URETHRAL FEVER. 193 

and the galvanic current used, but without avail, the 
patient dying in something less than five minutes. 

At the post-mortem a thorough examination of all 
the vital organs was made, but everything was found 
perfectly healthy, with the exception of the kidneys, 
which were so extremely congested that they presented 
a bluish appearance similar to that of the spleen. This 
fatal result was surely not attributable to the cocaine, but 
was evidently due to the sudden explosion of poisonous ma- 
terials which had been gradually accumulating in the sys- 
tem as a consequence of imperfect action of the kidneys and 
the metabolic action of slight surgical shock upon the tis- 
sues. This condition of toxicaemia gradually grew more 
pronounced and finally was so severe that a compara- 
tively slight irritation was sufficient to inaugurate a ner- 
vous explosion. Such an irritation was afforded by the 
mechanical effect of the injection of cocaine, and it is 
probable that the introduction of simple water would 
have had a similar effect. 

The danger of the development of tirethral fever is 
directly proportio7tate to the depth of traumatic and surgi- 
cal injuries of the tirethra i. e. their distance from the 
meatus. Those situated in the pendulous portion of the 
urethra are not, as a rule, very dangerous as compared 
with those situated in the fixed or deep portion of the 
canal. The explanation of this is very simple, the nerve 
supply of the deep urethra being much more abundant 
and sensitive, the cellular tissue more abundant, and the 
opportunities for drainage much less favorable than in 
the pendulous urethra. Decomposing urine is less 
apt to remain behind a stricture in the pendulous por- 
tion of the canal than in the deep portion, this being 
due to simple gravity and to the fact that strictures of 
this portion of the canal are usually of large calibre. 
Urinary extravasation in the pendulous portion of the 
urethra is not apt to produce serious danger to life, in- 
asmuch as the connective tissue in this situation is very 

13 



I Q4 STRICTURE OF THE URETHRA. 

sparse and the extravasated fluid is likely to be detected 
before it has burrowed back into the perineum. 

The relation of germ infection, or the absorption 
of the products of germ evolution, to the septic varie- 
ties of urethral fever is a most important one. This is 
abundantly proven by the researches of Guyon, Clado, 
Krogius, Albarran and many others, — investigators 
whose testimony is unimpeachable. 

The clinical features of the various morbid phe- 
nomena included under the head of urethral fever re- 
quire some special consideration: 

The nervous form of the disease usually appears in 
patients of an impressionable constitution, or who, in 
other words, present a decided tendency toward neu- 
rotic disturbances. Oftentimes its occurrence may be 
anticipated by the behaviour of the patient while he is 
under instrumentation. Pie is quite apt to have nausea, 
perhaps vomiting, slight rigors, partial or complete 
orgasm, or more or less complete syncope during the 
introduction of instruments in the deep urethra. Such 
patients are apt to develop, within twenty-four hours 
after urethral operations or injuries as a rule, a sharp 
chill. This lasts for a variable time, being rarely pro- 
longed, and then disappears, leaving the patient about 
as well as before, with the exception perhaps of more 
or less mental depression. Rarely indeed, there may 
be a slight amount of fever or sweating. The chill may 
come on within a very few minutes after the operation. 

The traumatic form is the most common; it mani- 
fests itself by a sharp chill, usually within twenty-four 
hours after operations or injuries of the genito-urinary 
tract, and is followed by pronounced fever and sweat- 
ing. The disturbance either passes off after a single 
paroxysm, or is followed by a period of general malaise, 
with perhaps a recurrence of the paroxysms for several 
days. In these latter cases there is present in all prob- 
ability a slightly septic element. 



URETHRAL FEVER. 1 95 

The third form — the typical urine fever — may or may 
not be attended by a violent chill coming on within 
twelve to thirty-six hours. There are marked prostra- 
tion, violent vomiting and diarrhcea, coldness of the 
surface of the skin at first, succeeded by more or less 
febrile movement of temperature later on if the patient 
survives, with suppression of urine, merging in a very 
short time in fatal cases into coma of an apparently 
uraemic type. I say u apparently vircentic type' becaitse ac- 
cording to the theory I have advanced regarding the action 
of shock ^lpon the urine, there is probably in many cases a 
toxic element present which is independent of tcroemia. 
Cases of this kind may come on gradually and manifest 
themselves by a sudden explosion in the form of con- 
vulsions, as is illustrated by the fatal case that has just 
been related. 

The fourth or septic form of urethral fever manifests 
itself usually by a slight (but sometimes by a very 
severe) chill: this is followed by fever of a varying de- 
gree of severity. The patient may sink into a typhoid 
condition, or become comatose, and die within from 
two to ten days from acute septicaemia, or the condition 
may be subacute and merge into the pyogenic form of 
septaemia, known more familiarly as pyaemia, in which 
event the patient finally succumbs to the slow develop- 
ment of circumscribed or diffuse purulent deposits in 
the joints, viscera and other structures of the body, de- 
pendent upon infection with pvogenic microbes and 
their products. 

The fifth or chronic form of tirine fever may be de- 
scribed as a chronic condition of toxicaemia and ner- 
vous irritation produced by long continued obstructive 
and inflammatory affections of the genito-urinary tract. 
This condition of toxicaemia and general nervous irrita- 
tion is one which is not generally recognized, but which 
is very important in its relations to chronic genito- 
urinary disease. It exists in the majority of cases of 



iq6 stricture of the urethra. 

organic stricture of long standing, in old men suffering 
with prostatic hypertrophy, in tumors ot the bladder, 
in chronic cystitis from whatever cause it may arise and 
in pyelitis, particularly the form due to the presence of 
nephritic calculi. There is a marked tendency in pa- 
tients suffering with these affections to a mild form of 
hectic fever; flushing of the face with slight elevation 
of temperature and perhaps followed by a certain de- 
gree of perspiration, are quite common; nervous irrita- 
bility is especially marked. Indeed, there are few con- 
ditions that are productive of so much mental depression 
and of so much irritability of temper as chronic dis- 
eases of the genito-urinary tract. The old man with a 
vesical calculus or prostatic hypertrophy, or for that 
matter, the young man with a stricture, is apt to be un- 
reasonably morose and irritable. In all of these cases 
there is apt to be present more or less obscure rheu- 
matic or neuralgic pains in various situations. After 
prolonged retention of urine from any cause whatever, 
it will be found that the majority of patients will suffer 
for a few days or w T eeks from more or less marked ele- 
vation of temperature. 

The different general conditions which have been 
outlined are due in my opinion to a toxicaemia which is 
dependent upon (a) imperfect elimination of the pro- 
ducts of retrograde tissue metamorphosis; (b) to a 
greater or less degree of absorption of morbific mater- 
ials produced by inflammation and the decomposition of 
residual urine behind the site of obstruction i. e. 
pseudo-alkaloidal germ products. It will be observed 
that many patients suffering from chronic genito- 
urinary disease of an obstructive or chronic char- 
acter, fail to realize how sick they are until the dis- 
eased condition has been removed, or at least greatly 
improved; they then find that slight disturbances to 
which they had paid comparatively little attention and 
which they had never dreamed of attributing to their 



URETHRAL FEVER. IQ7 

urinary trouble, have disappeared. This is due in great 
measure to the fact that reflex nervous irritation has 
been relieved, but more than this, it is due to the fact 
that the constant absorption of poisonous materials 
from the site of disease or above it no longer occurs. 

I have designated a sixth or mixed form of so-called 
urethral fever. It is probable that few cases will be met 
with that cannot be assigned to one or the other of the 
first five varieties of disturbance that have been de- 
scribed; it is to be expected that cases will occasionally 
occur in which there exists in varying proportion evi- 
dences of septic disturbance and of uraemia, with possi- 
bly a tendency to disturbance of the nervous functions. 
A clinical differentiation might in such cases be imprac- 
ticable. 

It is obvious that the range of cases which may 
properly be classified as urethral or urine fever is rather 
limited. Those cases resulting from septaemia and sur- 
gical shock are certainly improperly so classified. 

.It has been my experience that patients suffering 
from paludal poisoning, are especially apt to develop 
chill and perhaps fever, after genito-urinary manipula- 
tions. 

TREATMENT OF THE CONDITIONS USUALLY TERMED URE- 
THRAL FEVER. 

The principal measures of treatment of the mor- 
bid phenomena following genito-urinary operations are 
of a prophylactic character, for unfortunately for the 
patient y the marked forms of the disease i. e. the septic and 
urczmic varieties ', are seldom recovered from. The princi- 
pal feature of prophylaxis should consist of strict atten- 
tion to the principles of genito-urinary hygiene. If the 
functions of the kidney are stimulated by alkaline 
diuretics, and the skin and bowels kept in an active 
condition, thus affording vicarious relief to the kidney, 
the patient is placed in the best possible condition to 



I98 STRICTURE OF THE URETHRA. 

avoid those complications which have been described. 
In addition to these measures, moderate doses of anti- 
septic drugs may be given internally. Of these, boric 
acid in ten grain doses, as recommended by that excel- 
lent authority, Professor Palmer, of Louisville, is one of 
the best.* Salicylic acid or preferably the salicylates of 
soda, and the oil of eucalyptus are admirable remedies. 
Local antisepsis in cases of chronic bladder and pros- 
tatic disease is of course essential and can be accom- 
plished by irrigation with mild antiseptic lotions, such 
as carbolic acid, borate of soda, or boric acid, potassium 
permanganate and the bichloride of mercury. The sur- 
geon should avoid operating upon cases complicated by 
structural renal disease if it is possible to do so; if an 
operation be unavoidable he must not only be very 
careful in his manipulations, but should throw the re- 
sponsibility of the result entirely upon the patient and 
his friends. Prior to operative interference, particular 
attention should be paid to the urine and to local anti- 
sepsis. The patient should be put to bed and instructed 
to remain perfectly quiet; he should be placed upon a 
milk diet and moderate doses of quinine; 5 grains three 
times daily, for a week or ten days previous to the time 
appointed for the operation, being about the required 
dose. 

Various drugs have been recommended for admin- 
istration just before or at the time of urinary manipula- 
tions or operations. Quinine and morphine in ten and 
one-fourth grain doses respectively are the most popu- 
lar remedies and unquestionably have a conservative 
effect by increasing the resisting power of the nervous 
system and thus lessening the liability to shock. Jabor- 
andi is also recommended for the same purpose, and in- 
asmuch as its physiological action is such that it must 
necessarily relieve any strain upon the kidney, this drug 

*It would seem proper that Dr. Palmer should receive credit for the introduction of this 
remedy as a urinary antiseptic. For some reason he has not in certain quarters, received 
the credit due him. 



URETHRAL FEVER. 1 99 

seems to me to be one of our most philosophical reme- 
dies. Hypodermic injections of the muriate of pilocar- 
pine may be given instead of the fluid extract of jabor- 
andi, and in case uraemia supervenes this method of ad- 
ministration is absolutely essential. Diuretin has been 
highly endorsed by Dr. Keyes, 

The milder cases of disturbance (the nervous and 
traumatic forms) are rarely fatal, but may possibly lead 
to the severer forms of the disease and consequently 
require our attention. The administration of opium 
and jaborandi, with perhaps (in the traumatic form of 
the disease) aconite or veratrum viride constitutes the 
best treatment at our command. If uraemia oc- 
curs, our attention should first be directed to 
the vicarious elimination of urea, for we cannot afford 
to waste valuable time in attempting to restore the 
functions of the kidney within the first few hours after 
the supervention of uraemia, particularly if coma has 
occurred. Pilocarpine will act upon the skin, even when 
the patient is in a comatose condition, and it should be 
given freely. The bowels should be moved by croton 
oil, two or three drops of which in combination with 
five or six drops of olive oil, may be placed upon the 
back of the tongue. If the patient is able to swallow, 
elaterium in doses of from one-eighth to one-third of a 
grain is preferable to all other hydragogue cathartics, 
Hot baths should be given and dry or wet cups applied 
over the region ot the kidneys. Digitalis may be given 
internally as a diuretic after the emergency is over, but 
it is bad practice to attempt to accomplish anything by diu- 
retics before vicarious elimination of urea has been at- 
tended to. 

Urethral irrigations with solutions of bichloride, i 
in 20,000, before and after manipulations of the canal 
will prevent in the majority of instances the occurrence 
of septic infection after genito-urinary manipulations. 

Measures to insure a perfectly aseptic condition of 



200 STRICTURE OF THE URETHRA. 

the instruments used for exploration and dilatation of 
the urethra constitute an important means of prophyl- 
axis of septic manifestations. Sounds when introduced 
should be carefully warmed and lubricated with some 
antiseptic substance, and care should be taken that they 
are perfectly smooth. 

When septicaemia or pyaemia develops in spite 
of all our precautions, very little can be done 
in the majority of cases beyond supporting the 
powers ot life by free stimulation, a fatal result 
being almost inevitable. It is however, the duty of the 
surgeon to attempt to avert a fatal result by incision 
and drainage where possible, and if the case is clearly 
septic, a free incision at the site of the stricture or a 
perineal or supra-pubic cystotomy in cases of bladder 
and prostatic trouble, constitutes the proper surgical 
procedure. 

The management of cases of chronic urinary tox- 
aemia consists in local antisepsis by irrigation, and the 
prompt removal of the organic conditions upon which 
the gradual and constant septic infection depends. 

Nervous manifestations attendant upon the intro- 
duction of a sound and bearing a certain relation to so- 
called urethral fever are so frequently seen that 
they are worthy of special consideration, even 
at the risk of some repetition of points embraced 
in the preceding general discussion. There exists 
in some individuals of a nervous temperament extreme 
hyperaesthesia of the urethral mucous membrane, and 
particularly that of the prostatic portion of the canaL 
The nerves of sexual sensibility are apparently involved 
in the hyperaesthesia and enter into the causation of the 
direct and reflex nervous results of instrumentation. 
Shivering, a sense of faintness, cold perspiration and 
perhaps nausea, are not infrequently noted during the 
passage of instruments into the bladder. These symp- 
toms usually begin as soon as the instrument enters the 



NERVOUS MANIFESTATIONS FOLLOWING DILATATION. 201 

membranous urethra, and increase as the neck of the 
bladder is approached. They usually pass off im- 
mediately, but may recur and constitute the nervous 
form of urethral fever already described. 

The precise cause of these nervous manifestations 
would be difficult to determine. They are probably 
due in the first instance to an impressionable nervous 
system and timidity. They may, however, occur in 
individuals of strong constitution and of undoubted 
physical and moral courage. There is nevertheless no 
question but that a dread of the operation of dilatation 
has much to do in the causation of the nervous phe- 
nomena described. I have found, for example, that 
severe pain and spasm usually occur in individuals who 
have a dread of the treatment, and in such patients 
considerable depression following the operation is by no 
means unusual. 

In this connection it is well to remember the inti- 
mate association of the nervous supply of the genito- 
urinary tract, — and particularly the parts about the neck 
of the bladder and prostate, — with the sympathetic 
ganglia. It is certainly true that in some individuals 
relatively slight disturbances of these parts produce a 
most profound and depressing effect upon the sympa- 
thetic nervous system, and incidentally upon all the vital 
functions. The modus operandi of such disturbances 
is probably through a reflex impression made upon the 
sympathetic ganglia, through irritation of the nerves of 
sexual and general sensibility supplied to the parts in- 
volved. Conversely, it will be found that stimulation 
of this region within certain limits has a decidedly 
stimulating and even tonic effect which is beneficial to 
the general system. There are many disturbances of a 
nervous character, which are purely reflex and referable 
to irritations of the sexual apparatus independently of 
the previous existence of actual inflammation in these 
parts. As a matter of common experience it is noted 



202 STRICTURE OF THE URETHRA. 

that inflammations about the neck of the bladder and 
prostate are attended by relatively greater constitutional 
depression than similar morbid conditions of apparently 
much greater importance, located in other situations. 
This is only explicable upon the theory of the reflex 
impression produced upon the sympathetic nervous 
system. 

Urinary fever — and even minor nervous disturb- 
ances, — very rarely occurs in women, in whom the urethra 
is relatively mucn more insensitive than in the male. 
Then, too, the seat of sexual sensibility is not located 
in this portion of the female anatomy. Erichsen states 
that he has only once seen symptoms of urethral chill 
in the female. This was in the case of a young married 
lady, strong and healthy, who had a stricture of the 
orifice of the urethra which he dilated by a two-bladed 
dilator. Twenty hours after the operation she had 
three most intense rigors, followed by profuse sweating. 

The liability to nervous and febrile disturbances fol- 
lowing instrumentation of the urethra is modified to a 
great extent by the location of the morbid conditio7i which 
is being treated. Dilatation of stricture in any part of 
the urethra may produce such phenomena, but they are 
most likely to occur after operation upon strictures in 
the deeper portion of the canal, not because — as has 
been erroneously stated by some — the deeper portions 
of the canal are more commonly strictured, but because 
these parts are more closely associated with the nerves 
of sexual sensibility and with the filaments supplied by 
the sympathetic system. 

Erichsen speaks of one case in which a fatal chill 
followed incision and dilatation of the orifice of the 
urethra. A case of this kind might occur as a result of 
reflex inhibition of the function of the kidneys pro- 
duced by nervous shock. It is well known that 
strictures at the meatus often produce serious nervous 
disturbance, reflex spasm and vesical troubles, and it is 



NERVOUS MANIFESTATIONS FOLLOWING DILATATION. 203 

conceivable that an operation upon this sensitive part 
might have a very profound effect upon the nervous 
system in some cases. Such an effect, no doubt, might 
result in reflex hyperemia of the kidneys with complete 
inhibition of their functions and the supervention of 
uraemia, following the purely nervous manifestations 
induced by the operation. 

Urethral chill and fever are not very often met 
with unless some lesion of the mucous membrane exists, 
showing that a large proportion of these cases are due 
to the absorption of some toxic material. 

It is well to remember that, independently of all 
theoretical reasoning as to the precise causation of the 
various forms of urinary fever, there are certainly three 
elements to be considered, viz: (i) An impression of a 
purely nervous character; (2) a condition of toxaemia 
due to the absorption of septic materials from the 
affected mucous membrane, and (3) a toxic condition 
of the blood incidental to the retention in it of the pro- 
ducts of retrograde tissue metamorphosis incidental to 
inhibition of the function of the kidneys, and which in 
lieu of a better term we call uraemia. These three 
elements may exist singly or combined. When the 
condition goes beyond a purely nervous impression there 
may be a combination of all three elements. 

It has been noticed that the use of metallic in- 
struments is more liable to produce chill and subsequent 
manifestations of urinary fever than are the soft 
varieties. The only reason for this that I can suggest 
is that the soft instruments are used in comparatively 
small sizes and their introduction is so easy that it 
would be a bungling operator indeed who could succeed 
in producing injury; whereas even in skillful hands the 
use of the steel sound or a metallic catheter is likely to 
produce a relatively marked disturbance of the normal 
mucous membrane and of the lesion. The majority of 
sursreons who introduce instruments into the urethra 



204 STRICTURE OF THE URETHRA. 

are by no means extraordinarily expert in the necessary 
manipulations, and are therefore more likely to produce 
injury with a stiff and inflexible instrument than with 
one which is intrinsically harmless like the soft bougie. 

It is to be remembered that, as already suggested, 
a condition of chronic urcemta underlies many of the cases 
of rigor and fever following instrumentation of the 
urethra. The nervous system under such circumstances 
is in a perpetual state of irritability, and it is only 
necessary for some slight shock to occur to precipitate 
a nervous crisis. This shock is afforded in some in- 
stances by even the most delicate manipulations of the 
canal. 

The occurrence of the various symptoms which 
have been described, may be prevented in a large pro- 
portion of cases by gentleness in manipulation, and a 
careful study of the condition of the case at the time of 
each instrumentation. Like other accidents occurring 
in the course of treatment by dilatation of the urethra, 
much may be done in the way of prophylaxis, by care- 
ful observation of the exigencies of each particular 
case. Routinism is quite apt to be attended by annoy- 
ing or even disastrous results. It would not be at all 
surprising if cases of urethral fever should arise in the 
practice of an individual, who, regardless of the effects 
of previous instrumentations, and of the local and gen- 
eral conditions prevailing at the time of operation, di- 
lates all cases of stricture in a routine fashion every 
second or third day. The condition of the stricture 
itself as regards irritability has much to do with the lia- 
bility to the development of nervous manifestations fol- 
lowing attempts at dilatation. Given a highly irritable 
state of the contracted tissue, a primarily susceptible 
nervous organization, and chronic uraemia in combina- 
tion with unskillful attempts at instrumentation, and 
urethral chill — and perhaps fever — is almost inevitable. 

The administration of anodynes, the use of hot 



NERVOUS MANIFESTATIONS FOLLOWING DILATATION. 205 

baths, diaphoretics and other derivative and eliminative 
measures of treatment, with the careful use of cocaine 
in mild solution and moderate quantity at the time of 
the operation, are very useful in the prevention of dis- 
agreeable nervous results. The administration of mor- 
phia just before the operation in very sensitive patients 
— or just after the operation as a matter of routine, 
until the tolerance of the patient for instrumentation 
has been established — is a very useful measure. Qui- 
nine, morphia, jaborandi — and perhaps diuretin — are 
the only remedies which are generally recognized as val- 
uable in the prevention of urethral chill, and it is note- 
worthy that they are all remedies which act selectively, so to 
speak, ^Lpon the nervous mechanism. Eucalyptus, however, 
I know to be of great value, especially where the 
malarial cachexia exists. The use of hot antiseptic 
irrigations of the canal before and after operation in 
cases in which the phenomena of urinary fever are 
to be apprehended, is a very rational procedure, as 
has been already suggested. Where the operation of 
dilatation produces severe shock it may be necessary 
to administer hot toddy, or some other form of stimu- 
lant. I have found that the use of the Mariani wine of 
coca is beneficial to patients of a very impressionable 
temperament. 

When it is found that serious nervous disturbance or 
urethral fever follows each operation of dilatation, some 
other and more radical measure of treatment must be sub- 
stituted for it. A radical operation by divulsion or ure- 
throtomy in such cases is far safer than dilatation and 
constitutes the only feasible method of cure. 

Regarding the possibility of the occurrence of ner- 
vous manifestations from the introduction of a sound, 
it may be well to reiterate one point, which is that the 
surgeon should avoid the introduction of an instrument 
with the patient in the standing posture, until the de- 
gree of tolerance of the nervous system has been thor- 



206 STRICTURE OF THE URETHRA. 

oughly established. It is a very unpleasant thing to 
have a patient fall upon the floor in a dead faint while 
an instrument is being introduced — an accident by the 
way which has happened to me several times, in cases 
in which, for the sake of convenience and for the pur- 
pose of economizing time, I had ventured to introduce 
an instrument with the patient in a standing posture. 

Extreme sensibility of the urethra, and incidentally 
of the nervous system, are very frequently observed in 
cases in which the urethra is being operated upon for 
the first few times. This local and general hyperes- 
thesia, however, becomes blunted as a consequence of 
the local and constitutional effects of instrumentation 
within a comparatively short time, and after a few 
seances it will be found that the operation will be well 
tolerated. In some exceptional cases, however, the ure- 
thra remains permanently intolerant of the introduction 
of instruments, and no matter for how long a period 
the treatment may be continued, severe spasm, nervous 
shock and perhaps rigors will be produced by instru- 
mentation. 

HEMORRHAGE AND FALSE PASSAGES. 

Hcemorrhage is a frequent result of the introduction 
of instruments for the cure of stricture. As a rule, how- 
ever, I think that its occurrence is an indication that 
undue force has been used. In nine cases out of ten, 
when the operation of dilatation is productive of haem- 
orrhage it may be inferred that the instrument used is 
too large or that too much force has been used. 
An instrument which will enter the bladder by its 
own weight will very rarely produce bleeding, as 
the separation of the stricture tissue is accomplished in 
a very gentle manner and the pressure exerted is very 
moderate. In very tight strictures, and in those in 
which there is considerable congestion and spasm, the 
introduction of any instrument, however small, is liable 
to produce haemorrhage. When, therefore, I find that 



HAEMORRHAGE. 207 

the introduction of an instrument which will enter the 
bladder without the employment of force, is followed 
by bleeding, I infer that there exists considerable 
congestion at the site of the stricture. The haemor- 
rhage per se is not injurious, but on the contrary 
is very beneficial by producing local depletion. If, how- 
ever, it results from forcible catheterization, the reac- 
tion following the traumatism produced by the instru- 
ment more than counterbalances any possible benefit 
which could be derived from the local abstraction of 
blood. 

Some cases in which congestion exists as a predom- 
inating condition, will bleed occasionally after the act 
of urination, and particularly if the patient has recently 
indulged in intercourse, or has become sexually excited. 
Strictures of this sort are particularly apt to occur in 
intemperate individuals, or those -who have suffered 
from syphilis. Under such circumstances the utmost 
gentleness in the introduction of instruments will not 
prevent the occurrence of more or less bleeding. It is 
rarely if ever necessary to treat the haemorrhage; in 
fact it should be allowed to continue within reasonable 
limits. Should it however become excessive, the appli- 
cation of the cold water coil or an ice-bag will be all 
that is necessary to check it. 

False passages are a more frequent result of the in- 
troduction of sounds and bougies than is generally be- 
lieved. They are produced by the passage of the in- 
strument through the urethral walls into the surround- 
ing tissues. The mucous membrane only may be torn 
up — in which case, the passage rarely extends for a great 
distance — or the corpus spongiosum may be entirely 
penetrated and the tissues of the perineum entered. 
The danger of their occurrence is greatest with small 
metallic instruments, it being difficult to produce them by 
means of flexible bougies or catheters. The common 



208 STRICTURE OF THE URETHRA. 

English catheter with the stylet is, however, nearly as 
dangerous as metallic instruments. 

In pack thread or bridle strictures numerous 
pockets are apt to exist in the canal, or there may be a 
sort of membranous diaphragm thrown obliquely across 
the urethra in such a fashion that the instrument im- 
pinges upon it at its junction with the urethral walls, in- 
stead of entering the orifice of the stricture. Under such 
circumstances the conditions necessary to the produc- 
tion of a false passage are very favorable, and it takes 
but little force to perforate the urethra. 

SYMPTOMS. 

The occurrence of this accident is usually quite evi- 
dent at the time of operation. The surgeon is usually 
conscious of having used considerable force, or of care- 
lessness in respect to conforming the instrument to the 
natural direction of the urethra. The obstruction sud- 
denly yields to the pressure, and the direction of the 
handle of the instrument demonstrates the fact that the 
point is thrown out of the proper line. If the handle 
of the instrument be rotated between the thumb and 
fingers, it will be found that the point is fixed, thus 
showing conclusively that it cannot have entered the 
bladder. When the bladder is entered in the proper 
manner the point of the instrument is usually freely 
movable within the cavity of the organ, and there is no 
sense of resistance imparted to the handle when it is 
rotated. 

Under very exceptional circumstances the instru- 
ment may not only be forced through the urethral walls 
into the tissues outside it, but maybe passed completely 
on until the bladder is perforated. Coincidentally with 
the alteration in the direction of the instrument the 
patient complains of severe pain and perhaps a sense 
of impending syncope, and is apt to assert that some- 
thing has been torn. Free bleeding almost invariably 



FALSE PASSAGES. 209 

results. If a rectal examination be made, the beak of 
the instrument may be detected in the connective tissue 
lying between the vesical and rectal walls. 

False passages are most usually formed in the deep 
urethra, as it is in this situation that the lever action of 
a sound can be exerted to the best advantage, and 
moreover it is here that strictures so tight as to demand 
the use of small instruments are usually found. It is 
not so easy to produce false passages in the pendu- 
lous urethra, as the point of the instrument is contin- 
ually under the control of the fingers, and its proper 
direction is very easily maintained. The danger of their 
occurrence should, however, be borne in mind. 

The danger of false passages is directly proportion- 
ate to their distace from the meatus. Their direction 
is usually to one side of the canal. They may however 
perforate beneath it or above it. When they occur 
above it they are not likely to penetrate for a great dis- 
tance, on account of the firmness of the tissues. The 
corpus spongiosum, or even the prostate, may be com- 
pletely perforated when the false passage occurs below. 

The character of the perforation has also much to 
do with the degree of danger. When the false passage 
enters the corpus spongiosum and runs along the 
urethra, perhaps to open again into the canal, or if 
the bladder be entered after a lateral lobe of the 
prostate has been perforated, the danger to life is com- 
paratively slight. When, however, it passes clear out- 
side the corpus spongiosum into the vesico-rectal areolar 
tissue, serious extravasation of urine may result, with 
the consequent occurrence of inflammation, suppura- 
tion and perhaps gangrene of the tissues. These acci- 
dents are very frequently fatal. 

Old false passages are an occasional very annoying 
complication of stricture, and very frequently interfere 
not only with the treatment, but prevent a perfectly suc- 
cessful result as far the relief of the symptoms is con- 
14 



2IO STRICTURE OF THE URETHRA. 

cerned, even though the calibre of the canal be restored. 
As a rule, the history elicited from the patient is suf- 
ficient to justify a suspicion of the formation of a false 
passage or passages, at some previous instrumentation. 
The abnormal direction of the sound, the failure to 
enter the bladder, and the peculiar gristly sensation im- 
parted to the instrument are often sufficient to indicate 
its existence. Oftentimes the patient is perfectly aware 
of the presence of false passages, and will so inform the 
operator. Occasionally he will know that the abnormal 
channel has been penetrated by the instrument when 
its course is not evident to the surgeon. In some in- 
stances, only the most careful study of the symptoms 
and course of the case under treatment will enable us 
to determine the existence of false passages. 

Inflammation of an acute character affecting the 
urethra, prostate, bladder and epididymis, is by no 
means infrequent as a complication of stricture, arising 
as a direct consequence of injury produced by instru- 
mentation. There is of course, following all efforts at 
dilatation of a stricture, a moderate amount of result- 
ant inflammation. This inflammatory reaction how- 
ever, may be limited to the stricture itself. There may 
occur on the other hand, quite a sharp attack of ure- 
thritis. Much depends on the condition of the urethra 
at the time of dilatation; of more importance, however, 
is the condition of the sound as regards cleanliness. 

Inflammation of the prostate, incidental to the 
rough or careless introduction of instruments, or for 
that matter, to the careful passage of very large instru- 
ments, is an occasional result of dilatation. It should 
be remembered in this connection that the prostate is 
invariably in an irritable and perhaps congested and 
enlarged condition, as a secondary result of the stric- 
ture, or rather as a consequence of the bruising to 
which the organ is subjected during the frequent and 
spasmodic efforts at urination which are required for 



INFLAMMATORY COMPLICATIONS OF DILATATION. 21 T 

the evacuation of the bladder. In the presence of this 
condition of affairs comparatively slight traumatism is 
sufficient to excite prostatitis. This may appear in an 
acute form as a consequence of a single act of vio- 
lence, or it may appear in a subacute or chronic form as 
a result of repeated bruising and irritation. Abscess 
may occur, especially if infection be produced by a septic 
sound. 

Cystitis in the course of stricture arises in several 
ways: (i) It may be, due to actual violence done to 
the neck of the bladder by the use of large instruments. 

(2) It may occur as a consequence of irritation pro- 
duced by the prolonged contact of instruments, whether 
soft or metallic, with the neck of the bladder in the 
treatment by continuous dilatation. Ulceration of the 
bladder walls may result in a similar manner, as a con- 
sequence of pressure produced by the point of the sound. 

(3) Pre-existing chronic cystitis of the vesical neck, due 
to direct extension of inflammation from the stricture, 
may be so enhanced by the irritation produced by the in- 
troduction of instruments that acute generalized cystitis 
and perhaps pericystitis results. (4) A small quantity 
of poisonous material which is formed by bacterial evo- 
lution posterior to the stricture in the dilated portion 
of the urethra, is carried by the point of the instrument 
into the neck of the bladder and there sets up acute 
inflammation. 

The relation of bacterial organisms — not necessarily 
specific — to the morbid processes at the site of stricture and 
to cystitis is a very important one. 

(5.) Poisonous material, i. e. bacterial organisms 
or their products, may be conveyed to the bladder 
through the medium of unclean instruments. 

Epididymitis is one of the most frequent complica- 
tions of stricture. It maybe produced in two ways: (a) 
by the production of acute inflammation at the site of 
the stricture, which extends down ro the mouths of the 



2 12 STRICTURE OF THE URETHRA. 

ejaculatory ducts and thence to the epididymis. (6) 
By the conveyance of organic poisons to the mouths of 
the ejaculatory ducts by means of the sound or 
catheter. 

These various complications of stricture may be 
avoided in most instances if the patient keeps quiet, is 
temperate, and follows directions implicitly, and more 
important still, if the surgeon is gentle in his manipula- 
tions and absolutely cleanly as regards his instruments. 
It is desirable for patients who are being treated for 
stricture to wear a suspensory bandage throughout the 
course of the treatment if the testes be at all sensitive, 
this measure being very valuable in preventing epididy- 
mitis. 



CHAPTER XI. 



OPERATIVE TREATMENT OF STRICTURE. 

DIVULSION. 

Divulsion of stricture consists of its rapid and forci- 
ble dilatation with the object of rupturing the morbid 
tissues. It originated, in all probability, in England, 
where it is still a very popular operation. 

Various instruments have been devised for the op- 
eration of divulsion. Some of these consist of sliding 
tubes of varying calibre which are forcibly introduced 
over a central guide. Another variety splits the stric- 
ture after the fashion of a wedge. "Still another, and 
the most popular variety, consists of several parallel 
blades separable by means of a powerful screw. 

Divulsing tubes were first used by Desault some- 
thing like a hundred years ago. They are used in the 
following manner: A small bougie is introduced into the 
bladder as a guide, over this an open-ended catheter is 
passed, and over this another catheter or tube a trifle 
larger, as much force as is necessary being used. A suc- 
cession of tubes of increasing size are passed until the 
urethra is dilated to its fullest capacity. 

Divulsion upon the wedge principle was first recom- 
mended by Reybaud, and has been modified to a certain 
extent by Mr. Holt of England. Holt's instrument con- 
sists of two grooved blades of strong metal joined at 
their points. Between the two blades and fastened to 
them at their point of junction is a wire which acts as a 
guide; over this wire a tube of considerable size is 
forcibly passed. This separates the blades and splits 

213 



214 



STRICTURE OF THE URETHRA. 



the stricture. It is claimed by Holt that the rupture 
produced by the instrument does not extend beyond 
the morpid tissue, the healthy urethra not being injured 
about it. The accuracy of this statement is certainly 
questionable. I do not believe it possible for a stricture 
of any extent to be ruptured without injury to the 
urethra. 




Fig. 58. Holt's Divulsor 



Fig. 59. Thompson's Divulsor. 



Divulsors with separable blades are the most popu- 
lar instruments for the purpose of rupture of strictures. 



DIVULSION OF STRICTURE. 21 5 

Various patterns of the screw divulsor have been de- 
vised; they have been made with two, three and four 
blades. The best divulsor is probably that of Sir 
Henry Thompson, which has two strong, separable, par- 
allel blades. This instrument may be used for the pur- 
pose of rapid dilatation, by slowly separating the blades 
with successive turns of the screw, or it may be used to 
rupture a stricture by rapidly separating the blades as 
as possible. When the operation has been slowly done 
there is very little bleeding, and in all probability little 
or no laceration of the wall of the urethra. It is not 
apt to be successful, however, unless complete rupture 
is produced, in which event there may be considerable 
bleeding. 




Fig. 60. Gouley's Rapid Dilator. 



Divulsion at the present time is not very popular 
among the leading surgeons in America. It still how- 
ever has many advocates in England and on the con- 
tinent, where urethral surgery is far behind that of 
America. The operation appears to me to be a very 
unsurgical one, and unless considerable damage is done 
at the site of the lesion it is apt to fail of its object. 
Rapid stretching, unless attended by complete rupture 
of the stricture, will usually serve only to inflame and 
irritate the strictured tissue and cause it to become re- 
silient and elastic. It is, perhaps, a safer operation than 
internal urethrotomy in the deep urethra; but external 
perineal section is safer by far than either of these 
operations in cases of pronounced stricture There are 



2l6 STRICTURE OF THE URETHRA. 

however some indications for the use of this instrument, 
which are well outlined by Keyes as follows:* 

i. "To pass over a whalebone and in cases of very 
tight strictures so as to dilate them moderately, (a) 
In the anterior urethra in order that the large shaft of 
the dilating urethrotome may be made to pass, (b) 
In the deep urethra in order to make it possible to 
take up the treatment with sounds in gradual dilata- 
tion. 

2. "To divulse stricture of the deep urethra in the 
occasional cases where that operation seems to be called 
for when the patient refuses external perineal section 
and the choice lies between divulsion and deep exten- 
sive internal urethrotomy. 

3. "To pick up and remove small foreign bodies 
from the urethra." 

To the indications above presented I would add, 
resilient, elastic, and recurrent stricture of large calibre 
in the deep urethra. In these strictures dilatation is 
usually carried on until the morbid tissue is very slight 
in amount and involves but a superficial extent of the 
urethra and the sublying connective tissue. Under such 
circumstances urethrotomy may be objected to on ac- 
count of the danger of haemorrhage, and external pe- 
rineal section for such slight lesions is certainly a little 
severe. Divulsion, under these circumstances is a use- 
ful operation. Dilating urethrotomy carefully per- 
formed is occasionally justifiable in such cases. After 
the operation of divulsion Keyes recommends leaving 
a small catheter in the bladder for forty-eight hours. 
He says: "I have gradually come to the belief that 
such drainage of the bladder is of assistance in averting 
urethral fever in cases of divulsion and after deep 
internal urethrotomy. "+ The end of the catheter is left 

*Op. cit. 

fN. Y. Med. Jour., March 16, 1875. 



INTERNAL URETHROTOMY. 217 

open to drain into a urinal and the patient is kept in 
bed for about three days. 

The treatment should be continued by gradual dila- 
tation. A steel sound of moderate size is to be intro- 
duced four or five days after the operation, the time 
varying with the amount of inflammation resulting from 
the rupture of the stricture. An instrument should be 
passed at first every other day, the intervals being sub- 
sequently lengthened. 

INTERNAL URETHROTOMY. 

Internal Urethrotomy consists in the division of the 
stricture by cutting instruments. These are practically 
of three kinds — viz. (i) those which cut the stricture 
from before backwards; (2) those which cut from be- 
hind forwards; (3) those which, in addition to a cutting 
blade passed through a hollow central guide, have two 
separable blades, the object of which is to complete the 
operation by divulsing or tearing any of the fibres of 
the stricture which may still remain after the incision. 
The instruments most frequently used are those of 
Maisonneuve, Civiale and Otis. Various modifications 
of the urethrotome have been devised by Van Buren, 
Gouley, Berkeley Hill, Wyeth and others. 

Maisonneuve's instrument cuts from before back- 
wards, and is serviceable for the division of strictures 
of the deep urethra. It consists of a hollow tube with 
a slit upon the side which corresponds to the floor of 
the urethra. Triangular knives of different sizes fast- 
ened to a wire shaft are passed along this central tube 
after its introduction into the bladder, until the stricture 
is divided. This urethrotome is supplied with a screw 
tip, to which a filiform bougie may be attached. The 
principal objection to the use of this instrument is that 
it never divides the stricture completely unless a very 
large blade is used, in which event much more cutting 



2l8 



STRICTURE OF THE URETHRA. 



is done than is absolutely necessary, and serious haem- 
orrhage is apt to result. 

Civiale's urethrotome has been a very popular one, 
but with the advent of the Otis instrument and its mod- 





Fig. 61. Gouley's Dilating UrethrotoVne. 



Fig. Fig. Maissonneuve's Urethrotome. 



ifications the simpler instrument of Civiale has fallen 
into disuse. It consists of a small shaft upon the end 
of which is a bulb with a slit upon one side. This slit 
contains an oval blade which may be protruded from 



INTERNAL URETHROTOMY. 



2IQ 



the s ce of the bulb by a sliding wire contained 
within the hollow shaft. The instrument is passed 
through the stricture and then withdrawn until the shoul- 
der of the bulb comes in contact with the posterior sur- 



o 



Fig. 63. Civiale's Urethrotome. 



Fig. 64. Otis Straight Dilating Urethrotome. 



face of the lesion. The blade is then to be protruded 
by the mechanism upon the handle and fixed in the de- 
sired position. The instrument is then withdrawn, the 
stricture being cut through from behind forwards. It 



220 



STRICTURE OF THE URETHRA. 



can only be used conveniently in the pendulous urethra. 

It has seemed to me to be a bunglesome instrument, and 

it is certainly far inferior to 
the Otis dilating urethro- 
tome. It is preferred by 
Thompson for operations in 
the penile urethra, but I 
must confess that I have 
never been able to use it 
with any degree of satisfac- 
tion. 

Otis' dilating urethotome 
is the best instrument that 
has so far been devised for 
cutting strictures in the pen- 
dullous portion of the ure- 
thra. The latest pattern 
consists of a straight tun- 
neled shaft with a second- 
ary blade, the two being 
separated by means of a 
powerful screw. The cut- 
ting blade is slipped along 
in a groove upon the central 
shaft. Attached to the han- 
dle near the screw is a dial 
plate. By this intrument 
the urethra may be cut — or 
dilated and cut — to a cali- 
bre of 45 French. 

The operation of dilating 
urethrotomy may be per- 
formed under cocaine, al- 
though it is perhaps better 

Fig. 65, The Otis Curved Dilating Ureth- f i 

rotomc - on the average to put the 

patient under full ether anaesthesia. Cocaine is not 




INTERNAL URETHROTOMY, 221 

always reliable, and it must be admitted that it is, so 
to speak, rather a tricky drug for general use. I do 
not, however, accept all the fatalities which have 
occurred under its application to the urethra, as 
due to the cocaine per se. Certainly, even those who 
do accept all such cases as evidences of the dangers 
of cocaine in genito-urinary surgery, must admit 
the existence of some peculiar idiosyncrasy in the 
fatal cases. Even ether is not above reproach in this 
respect. Laying aside for the nonce, all arguments for 
and against the drug, it is unquestionably a toxic agent 
of no mean power, which should be used with more 
circumspection than seems to be the rule. A two per 
cent, solution is usually strong enough, and may with 
advantage be made by dissolving the requisite amount 
of cocaine in a two per cent, carbolic acid solution, 
this being supposed to retard absorption of the cocaine 
and limit its action to a purely local effect. 

If an operation is necessary at all an anaesthetic of 
some kind is certainly warrantable. Under the use of 
cocaine the patient's apprehensions are not removed 
as they are by full anaesthesia, and the surgeon is apt 
to be less thorough in the operation than if satis- 
fied that the patient is entirely unconscious; in some 
patients of a nervous temperament therefore, full anaes- 
thesia is imperatively necessary. Prior to exploration 
of the urethra, and again before cutting is begun, the 
canal should be flushed out with a 1-20,000 bichloride 
solution. 

OPERATION. 

The number of strictures and the distance from 
the meatus having been estimated as accurately as pos- 
sible, the dilating urethrotome is passed down until the 
point upon the shaft at which the blade will first appear 
when withdrawn, corresponds with a point in the ure- 
thra about half an inch behind the stricture. The 



222 STRICTURE OF THE URETHRA. 

blades are now to be separated by turning the screw 
until tension of the stricture or strictures is brought 
about; the cutting blade is then to be steadily and with 
moderate rapidity withdrawn. The dilating blades are 
now separated to the required extent. They are then 
screwed together again and the instrument withdrawn, 
care being taken not to catch the mucous mem- 
brane between the blades during withdrawal. Ex- 
ploration with a full sized bulbous bougie should now 
be made to determine whether the strictures have been 
completely divided. Should the urethra not be per- 
fectly free, the urethrotome should again be inserted 
and used in the same manner as before. The operation 
is to be completed by the passage of a full sized steel 
sound. After the operation the urethra should be irri- 
gated with a hot saturated solution of boric acid or a 
bichloride of mercury solution, 1-20,000. The patient 
should be put to bed and an ice-bag or the cold water 
coil applied to the parts. 

The determination of the size to which the urethra 
should be properly enlarged involves some nicety of 
judgment. The only fixed standard that has ever been 
advanced is that of Dr. Otis already described. 

It would seem essential at this juncture to repeat 
the essential points of the Otis method. 

According to this authority the average size of the 
urethra, as determined by numerous measurements with 
the urethrameter, is as follows: When the circumferen- 
tial measurement of the penis is three inches the ure- 
thra should admit a sound No. 30 French. With each 
one-eighth of an inch increase in the circumference of 
the penis the urethra is supposed to increase one-third 
of a millimeter in diameter, that is, it should admit one 
size larger upon the French scale. Thus the circumfer- 
ence of the penis being 3 1-8 inches the urethra should 
take 31. With a circumference of 3^ inches, 32 and 



INTERNAL URETHROTOMY. 223 

so on. A circumference of 4% to 4% inches is rarely 
exceeded. In such cases the urethra should admit at 
least 40 French. Dr. Keyes' remarks upon this point 
will, I think, be indorsed by the majority of surgeons. 
He speaks as follows: "If the surgeon desires to en- 
large the patient's stricture as widely as he can in safety, 
and desires the test as to the limit in size of the sound 
which he shall use, I know of no better ultimate limit 
than the scale proposed by Otis, giving it as my personal 
opinion that while his limit may be safely aspired to and 
reached, it is wiser to fall short of the standard by a few 
sizes, in which case all the advantage claimed by Otis 
will be ordinarily secured, and some of the disadvan- 
tages of a urethra unnaturally wide will be avoided. 

"That these sizes may be safely attained, the long 
experience of Dr. Otis proves; that they are generally 
necessary I personally am not convinced. That they 
may sometimes be desirable I believe. The limit, how- 
ever, I consider a little too much for practical adoption, 
and I prefer in cases that will get well without reaching 
so large a size to disregard it; in others to scale down 
a few sizes, believing that as much good may be attained 
and some possible harm, and often some complaint from 
the patient averted." 

One of the principal objections to Dr. Otis' meas- 
urements is that they are liable in many cases to appar- 
ently demonstrate the existence of a stricture of large 
calibre at points of normal relative inelasticity of the 
canal. There is however, as a rule, no danger and no 
disagreeable results in all probability, to be apprehended 
from dilating the urethra after preliminary incision, 
to as great a calibre as is possible with the Otis instru- 
ment. Occasional cases may arise in which damage 
might be done. 

I have found that it is generally practicable, and, as 
a rule, advantageous to enlarge the urethra as recom- 



224 STRICTURE OF THE URETHRA. 

mended by Dr. Otis where urethrotomy is necessary; 
but I have not as yet succeeded in convincing myself 
that the size attained at the time of operation should 
be maintained by subsequent dilatation with sounds. 
In fact, it will often be found impracticable to maintain 
a calibre of more than 32 to 35 French, even where the 
urethra has been incised and stretched to the fullest 
capacity attainable by the Otis dilating urethrotome 
(45 French.) The enlargement of the urethra secured 
by the operation, even when the cutting is thor- 
oughly done, is to a certain degree temporary in 
character, being dependent upon overstretching of the 
muscular fibres of the urethral walls. This overstretch- 
ing makes the urethra flaccid, and for a few days a 
large sized sound will be admitted; but after a time the 
tonicity of the urethra is restored, and as a consequence 
an instrument of the size which it was practicable to in- 
troduce immediately after the operation, can no longer 
be passed without the exhibition of undue force and 
the production of considerable pain and spasm. In 
fact, the permanent calibre of the urethra, which it is 
practicable to secure by the operation, is usually some 
sizes smaller than that primarily secured. 

In strictures of large calibre, within two and a half 
inches from the meatus, I have operated successfully 
through a urethral speculum such as shown in Fig. 58, 
dividing the stricture with a sharp curved bistoury. 

In the performance of urethrotomy the rule should 
be, (a) to make the incision downwards at the meatus 
and a short distance within it, (6) to cut upon the roof 
of the canal in the penile urethra, (c) to cut downward 
in the balance of the canal, unless the curved Otis 
dilating urethrotome be used, in which event the direc- 
tion of the cut should be upward. 

UNTOWARD EFFECTS OF THE OTIS OPERATION. 

There is sometimes considerable inflammation fol- 



UNTOWARD EFFECTS OF URETHROTOMY. 225 

lowing the operation of dilating urethrotomy. This 
may give rise to chordee, which may last for some little 
time, perhaps leaving a curvature which persists for 
some weeks or even months after the operation wound 
has entirely healed. Dr. Otis claims that he has never 
seen a case where the plastic exudation causing such a 
chordee was not finally absorbed. He says: "Two cases 
have come to my knowledge where the frequent passage 
of sounds (daily) was kept up, notwithstanding an 
acute inflammation was present, and where curvation 
resulted which gave great annoyance for over a year. 
One where the introduction of sounds was daily prac- 
ticed for six weeks with so great pain that ether was 
required to effect it, and yet this case finally recovered. 
In the other, operated on a little over a year ago, ag- 
gravated in the same way, the curvature still persists. 



Fig. 66. Otis' Urethrotome for Diagonal Section of the Urethra. 

Such rare cases, evidently due to gross error in after- 
treatment, cannot legitimately count against the opera- 
tion when well and judiciously performed. Several 
cases of persistent curvation of the penis resulting 
slowly from gonorrhoeal inflammation and consequent 
stricture have come under my notice, and which have 
been reduced by the operation of dilating urethrotomy 
by cross section of the constricting band with an instru- 
ment especially devised for this purpose, dividing the 
stricture diagonally." 

I recall a personal case in which permanent and 
serious curvature resulted. In this case I performed 
urethrotomy upon two strictures in the penile portion 
of the canal. Through the patient's carelessness, in- 



226 STRICTURE OF THE URETHRA. 

temperance and sexual indulgence, a second operation 
became necessary a few months later. Shortly after 
the second operation the patient contracted a violent 
urethritis, a permanent chordee resulting. I proposed 
to perform the operation of diagonal section, recom- 
mended by Dr. Otis, but the patient declined further 
treatment. Fortunately, in this instance the patient 
was well aware of his own agency in the causation of 
his deformity. I have seen in several other instances a 
slight amount of curvature persisting for some little 
time. I recall but one instance, however, in which a 
sufficient length of time has elapsed since the operation, 
to determine whether the condition is apt to prove per- 
manent or not. In this case four years after operation 
there is still some curvature, but not enough to cause 
functional trouble. Several cases have passed from 
under my observation before a sufficient time had 
elapsed to enable me to base an opinion upon the per- 
manency of the condition. In none of the cases which 
I have seen, with the exception of the first mentioned, 
has the deformity appeared to be sufficiently marked to 
interfere with the function of the organ. I consider, 
however, that the danger of permanent curvature is to 
be taken into consideration in spite of the apparently 
favorable experience of Dr. Otis. Dr. R. W. Taylor 
admits its occurrence. Neither Taylor nor Otis, how- 
ever, are sufficiently clear upon this point. I fear that 
the prevailing tendency on the part of surgeons to 
withhold the records of their unfavorable cases, has 
pervaded urethral surgery. 

I have observed imperfect erection in several cases 
which lasted a year or more after urethrotomy. The 
complaint usually made is, that while the rest of the 
organ becomes normally erect, the glans remains soft 
and flabby. This is only explicable on the ground of 
cicatricial interference with the circulation of the organ. 



AFTER TREATMENT IN DILATING URETHROTOMY. 221 

With regard to the safety of dilating urethrotomy, 
Dr. Otis speaks as follows: "In my own experience of 
over qoo operations, not only have I never had a death 
or a permanent disability of any sort, but I can say today 
I have never performed the operation either to my own 
regret or without marked or acknowledged benefit to 
the person operated on. Prof. Taylor acknowledges 
several deaths from septicaemia following urethrotomy 
in the penile urethra.* 

Personally, I can only state that I have had thus 
far, no unfavorable results, yet I am not prepared to be- 
lieve that the operation is perfectly free from danger. 

AFTER TREATMENT IN DILATING URETHROTOMY. 

• 

I find that the prevailing tendency is to regard the 
operation of urethrotomy as a trivial matter requiring 
little attention to details. It is customary for example 
for the surgeon to operate at his office and allow his 
patient to go about as much as he pleases. This I hold 
to be wrong. Where it is possible to do so, the patient 
should, as a rule, be put to bed for at least a week. As 
an illustration of the unfairness with which the opera- 
tion of urethrotomy is sometimes condemned, I will 
mention a very pertinent case. A prominent prac- 
tioner in one of our western cities asked me if I advo- 
cated the operation of urethrotomy. On my replying 
in the affirmative he informed me that he had had 
bad results with it, the patient dying in one instance. 
On inquiring I found that the doctor was in the 
habit of operating at his office, and that in the fatal 
case the patient rode horseback after the opera- 
tion, some miles away, to his home and lost so much 
blood on the way that he died shortly after reach- 
ing his destination. It is hardly necessary to state 
that it was not the operation that killed this patient. 

*Bum stead and Taylor, p. 309. 



228 STRICTURE OF THE URETHRA. 

Personally, while I am occasionally compelled to oper- 
ate at my office, I am always uneasy regarding the sub- 
sequent course of the case. 

Cases occasionally occur in which there is little 
bleeding at the time of the operation, but very free 
haemorrhage comes on during the night as a consequence 
of an erection. This makes the application of cold a 
prime necessity. In one of my cases a very severe haem- 
orrhage followed an erection two weeks after operation. 
In addition to the application of cold I am in the habit 
of giving anaphrodisiacs after the operation. Ergot, 
bromide of potassium and gelseminum meet the indica- 
tions admirably. A suppository of hyoscyamus, mor- 
phia and monobromide of camphor has been of great 
service to me in these cases. 

It is my custom to give boric acid in fifteen grain 
doses three or four times daily after a urethrotomy. 
This drug keeps the urine bland and aseptic. The 
benzoate of soda, gaultheria, oil of eucalyptus and salol 
are also of service. 

It is my firm conviction that sounding is usually too 
vigorously carried on after urethrotomy. I have found 
that the danger of haemorrhage, urethritis and curvature 
of the penis has been directly proportionate to the as- 
siduity with which I have followed up dilatation after 
the operation. The best results follow infrequent di- 
latation beginning on the 2d or 3d day after operation— 
or even later if bleeding be profuse — and repeating the 
dilatation every 3d day for a week and then every 4th or 
5th day thereafter. My conservatism in this respect has 
been due to observation of dispensary patients who have 
been negligent after operation, and in whom infrequent 
dilatation has been perfectly successful. I do not be- 
lieve that there is much danger in allowing a stricture 
which has once been thoroughly cut, to go for an entire 
week without dilatation. The cut ends of the circular 



REMOTE RESULTS OF DILATING URETHROTOMY. 22Q 

muscular fibres probably retract, and this serves to keep 
the incision open sufficiently for all practical purposes. 
The dilatation of the canal by the urinary outflow, also 
plays an important role in maintaining the patency of 
the urethra. 

Permanancy of result. The claims of dilating ure- 
throtomy as advanced by Otis and his adherents have 
been chiefly based upon the permanency of result which 
the operation seems to secure upon the average. The 
only reliable test in any particular case is a re-examina- 
tion with the bulbs a considerable time after the opera- 
tion. It is safe to say that in most cases of stricture, 
appreciable recontraction will occur in a very short 
time — a few months perhaps — after treatment, if it occur 
at all. This may be disputed by those surgeons with 
whom the passage of an ordinary sound is a crucial test 
for stricture, but it will hardly be disputed by the 
andrologist who relies upon the burbs for his explora- 
tions. Recurrence is of course not likely to occur if 
systematic sounding be persisted in at regular intervals, 
hence old time cases of urethrotomy in which the sound 
has been used from time to time will not answer our 
purpose in testing the permanency of the result in di- 
lating urethrotomy. Otis, Mastin, Bevan and many 
others, have made careful re-examinations of cases 
operated upon by them at variable periods after opera- 
tion, and have found the majority of the cases to be still 
free from stricture. Mastin made re-examinations of 
eighty cases at periods varying from six months to four 
years after the operation and found the following : " In 
fifty-nine cases there was an absolutely perfect result, 
in twenty-one cases recontraction occurred in one or 
more strictures, upon twelve of which re-operations were 
made and subsequently dismissed cured, two had drifted 
away and six were waiting a favorable time for re-opera- 
ation." As Mastin tersely remarks, it is not the num- 



23O STRICTURE OF THE URETHRA. 

ber of cases, but the permanency of results that counts 
for the operation. A large number of cases operated 
within a few months are not nearly so valuable as a few 
cases several years after operation. 

My personal experience with the Otis method has 
been extremely satisfactory. The principal source of 
disquiet has been the frequent occurrence of curvature 
of the penis already expatiated upon. Regarding this 
feature of urethrotomy, I have been impressed with the 
fact that the severity of this symptom varies very greatly 
under conditions apparently precisely similar. I recall 
for example, a series of about twenty cases in which this 
symptom did not occur, and I was congratulating my- 
self upon the pleasant post-operative course of my cases, 
when a stubborn curvature developed in one of my 
patients. This case was followed consecutively by seven 
or eight others with a similarly annoying curvature. 
Fortunately however, none of these proved permanent. 

From an experience of thirteen years with the Otis 
method I can cordially endorse the claims advanced for 
its efficacy. I regret exceedingly that my records of 
operations are marred by the circumstance that in for- 
mer years I was in the habit of advising the use of the 
sound many months after operation as a matter of rou- 
tine. I do not at the present time consider it necessary, as 
a rule, to pass sounds after the operation wound has 
healed, for I have acquired great faith in the permanency 
of my results. Obviously, the cases in which I advised 
the subsequent use of the sound are of no value in esti- 
mating the radical nature of the operation. My experi- 
ence has comprised nearly four hundred operations up 
to date, most of which have been upon patients in pri- 
vate practice. I do not include cases in which strictures 
have been cut at or near the meatus unless deeper 
strictures have been cut at the same time. Of these 
cases I have had the opportunity to examine under 



suitable circumstances but thirty-five, and in ten of these 
in which recontraction had occurred, there had been re- 
infection by gonorrhoea. These latter cases are ob- 
viously unfair criteria for judging the results of opera- 
tion. In several cases recontraction had not occurred 
in spite of a recurrence of gonorrhoea. I append brief 
notes of each of the series of cases, omitting those in 
which recontraction occurred probably as a result of 
reinfection. 

Case I. Congenital stricture of meatus, two stric- 
tures of moderately calibre in the penile urethra. Gleet 
of seven years standing. Operated upon by dilating 
urethrotomy in 1881. This case has been under obser- 
vation at intervals ever since and has had in the interim 
a fresh attack of gonorrhoea which occurred two years 
ago. Careful examination with the urethrameter since 
the attack of gonorrhoea mentioned has failed to de- 
tect the slightest recurrence of stricture. This patient 
had been advised to use the sound from time to time, 
but had failed to do so through inadvertency. He had 
been a hard drinker and quite a high liver. 

Case II. Operated in 1880. Gleet of three years 
standing, following a fourth attack of gonorrhoea (so 
called) . Stricture just within the meatus. Another 
stricture was detected at a depth of three inches and a 
half in the penile urethra, with a third slight narrowing 
in the bulbo-membranous region. Meatotomy and 
dilating urethrotomy were performed upon the anterior 
strictures, the posterior being treated subsequently by 
dilatation. This patient was under observation for 
some little time on account of his gleet being perpetu- 
ated by posterior urethritis which was finally cured. I 
examined this patient 3 years after the operation, and 
found that the deep stricture had recontracted, but that 
the stricture which had been operated upon by dilating 



232 STRICTURE OF THE URETHRA. 

urethrotomy had not returned. In this case also sounds 
were not passed in the interval between the operation 
and date of re-examination. 

Case III. Operated in 1881. Moderately con- 
tracted meatus and stricture at a distance of two inches 
and a. half from the penile urethra. This patient had 
a chronic follicular prostatitis with more or less paren- 
chymals involvement, the organ being moderately 
enlarged and tender. Frequent and painful micturi- 
tion was a prominent symptom. After subduing the ir- 
ritation about the vesical neck I performed dilating 
urethrotomy. This case was re-examined at the end of 
a year and found to be perfectly free from stricture. 

Case IV. Obstinate gleet of 18 months duration 
following a second attack of gonorrhoea. Stricture of 
medium calibre at an inch and a-half, and a second at 
four inches in the pendulous urethra. Operation by 
dilating urethrotomy, meatus not cut. I re-examined 
this patient at the end of 18 months and again 2 years 
ago, and found the canal perfectly free. 

Case V. Operated in 1882. Patient presented 
himself complaining of frequent micturition; had suf- 
fered from a gleet until within six months of examina- 
tion, when it "dried up " spontaneously, after having 
lasted for six months. He had had two or three attacks 
of gonorrhoea. On examination a very tight stricture 
of the meatus was found, and just within the orifice a 
second stricture which would barely admit No. 5 French. 
At a depth of four inches in the penile urethra a third 
stricture was found which was excessively irritable and 
of quite small calibre. Meatotomy and dilating ure- 
throtomy. Re-examination in 1886 — four years after 
operation — showed no recontraction. 

Case VI. Operated in 1882. Moderately contract- 
ed meatus and a tortuous stricture admitting at the first 
sitting only a No. 7 French, beginning at two inches 



CASES SHOWING RESULTS OF DILATING URETHROTOMY. 233 

from the meatus and extending to a depth of about four 
and a half inches. Operated by dilating urethrotomy 
and meatotomy after preliminary dilatation by sounds 
for several weeks up to a calibre of No. 5 French, a 
plan which I consider a very excellent one where it is 
practicable to follow it. This case was re-examined in 
1885. There was slight recontraction at four inches 
and a half, at which point I again operated. This case 
was seen again in 1887, and there had been no recon- 
traction. 

Case VII. Meatus in this case was quite commo- 
dious. There were three strictures at an inch and a 
half, two and a half and four inches respectively. These 
strictures were all of quite large calibre with the excep- 
sion of the anterior one, which admitted only a No. 10 
French. Dilating urethrotomy. This case was re-ex- 
amined in 1884 and was perfectly free. In 1885 it was 
again re-examined. There was slight contraction of 
the posterior stricture, the remainder of the canal re- 
mained perfectly free. 

Case VIII. Operated in 1882. Gleet of seven 
years standing, contracted meatus and stricture just 
within it. Second stricture at a depth of three inches. 
Meatotomy and dilating urethrotomy. Case re-exam- 
ined in 1888. There was absolutely no recontraction, 
although the patient in the meantime had had an at- 
tack of gonorrhoea of two months duration. 

Case IX. Operated in 1883. Stricture of large 
calibre at a depth of an inch and a half, a second which 
admitted No. 10 French only at a depth of three inches 
and a half. Dilating urethrotomy. Meatus did not re- 
quire operation. Case re-examined in 1885 and again in 
1887, an d found to be perfectly free. Patient meanwhile 
had been quite a roue and had also drunk a great deal. 

Case X. Case operated in 1885. Contracted 
meatus, strictures of large calibre at a depth of two, 



234 STRICTURE OF THE URETHRA. 

three and three and a half inches, respectively. Meat- 
otomy and dilating urethrotomy. This case was re-ex- 
amined in 1888, and again in 1891, and found to be per- 
fectly free from stricture. 

Case XL Operated in 1884. Stricture at the meatus, 
another at two and a half inches, and a third at the 
bulbo-membranous junction. The latter was compli- 
cated by fistula and was a hard callous stricture, quite 
tortuous and involving the urethra from the bulbo- 
menbranous junction well forward toward the peno- 
scrotal angle. Operated by perineal section posteriorly, 
dilating urethrotomy and meatotomy anteriorly. This 
case was re-examined in 1885, about one year after the 
operation. There had been no recontraction of the 
strictures in the anterior portion of the canal, but the 
posterior stricture has recontracted to a moderate ex- 
tent, patient having had no sound passed since leaving 
my care after the original operation. Sounds were 
passed upon this patient at the time of this visit, and he 
disappeared from observation till 1886, when I re-ex- 
amined him. He in the meantime had not had sounds 
passed. I found quite a little recontraction of the deep 
stricture, but found the penile portion of the canal to 
be absolutely free from contraction. The rather rapid 
recurrence of the deep stricture was readily explicable 
on the ground of the dissipated habits of the patient. 

Case XII. Operated in 1886. A single stricture 
in the penile urethra at a depth of two inches and a half. 
Meatus sufficiently large. Operation by dilating ure- 
throtomy. Re-examined in 1890 and the urethra found 
to be absolutely free from recontraction. 

Case XIII. Stricture of the meatus, a second at 
an inch and a half, and a third at three inches, with an 
additional deep stricture at the bulbo-membranous 
junction. As the patient was from out of town and 
wished a method of operation that would give quick 



CASES SHOWING RESULTS OF DILATING URETHROTOMY. 2^5 

results, I divulsed the deep stricture, at the same time 
operating on those in the penile portion of the canal by 
dilating urethrotomy. The case passed from under my 
observation, and I did not see it again until a few 
weeks ago, i. e., early in 1892, when he again consulted 
me, stating that he had neglected to pass his sound as 
I had instructed him to do, since about a month after 
the operation, and that he thought his strictures were 
coming back upon him. On examination I was pleased 
to find that although recontraction had occurred in the 
deep urethra, the strictures in the penile portion had 
not recurred. 

Case XIV k Operated early in 1888. Contracted 
meatus and strictures at two inches and three and 
three-quarters inches respectively. Meatotomy and 
dilating urethrotomy. Re - examination November, 
1891, and found perfectly free from recontraction. 

Case XV. Operated early in 1888. Stricture at 
meatus, and a second at 2^ inches, abutting 15 and 20 
Fr. respectively. Dilating urethrotomy. Case re- 
examined in October, 1889, and the urethra found 
perfectly free throughout. 

Case XVI. Operated in November, 1888. Stricture 
of the meatus and just within it, and at 3^ inches. 
Meatus admitted only No. 10 Fr. The second stric- 
ture had a calibre of 20 Fr. In the perineum was 
a sinus leading down to a hard tortuous stricture of 
probably traumatic origin. The anterior stricture was 
due to gonorrhceal infection. Dilating urethrotomy 
and perineal section. Re-examination in 1890, and 
although sounds had been passd from time to time, re- 
recontraction was found to have occurred in both the 
anterior and posterior strictures. A second operation 
was proposed and refused. 

Case XVII. Operated in September, 1888. Meatus 
sufficiently capacious. Stricture of slight degree at 



236 STRICTURE OF THE URETHRA. 

bulbo-membranous junction, and two strictures of cali- 
bre 18 Fr. at 2 and 3^ inches respectively. Dilating 
urethrotomy of anterior strictures. Re-examination in 
1891, and both strictures were found to have recon- 
tracted. Posterior stricture only moderately recon- 
tracted. This case was re-operated, but has not since 
been re-examined. 

Case XVIII. Operated in Spring of 1889. Meatus 
strictured and three points of narrowing at 2, 3 and 3^ 
inches respectively. Dilating urethrotomy and meato- 
tomy. Re-examination eighteen months after opera- 
tion. No recontraction. 

Case XIX. Operated in Spring of 1889. Very 
tight stricture of meatus and a stricture of moderately 
large calibre at 3 inches. Tight stricture at bulbo- 
membranous region, complicated by a fistula of four 
years' duration. Perineal section proposed and refused. 
Meatotomy and dilating urethrotomy performed. Case 
treated for three months by dilatation; which by the way 
was not brilliantly successful. The fistula healed within 
a week after removal of the anterior obstructions. Re- 
examined January, 1892, patient having meanwhile 
neglected his case, no sounds having been passed since 
he stopped treatment with me. No recontraction in 
anterior portion of canal, and the deeper stricture, 
although recontracted, was not nearly so much so as I 
had anticipated. 

Case XX. Operated in November, 1889. Gleet of 
fifteen years standing. Stricture just within the meatus 
and a tortuous stricture beginning at a depth of two 
inches and extending back for a distance of two inches. 
Meatotomy and dilating urethrotomy. Re-examination 
in Spring of 1891, and found a slight stricture at bulbo- 
membranous junction, the balance of the canal being 
perfectly free. This patient had suffered from a slight 
urethritis in the interim. 



CASES SHOWING RESULTS OF DILATING URETHROTOMY. 237 

Case XXI. Operated in December, 1889. Stric- 
ture at 2>£ and 3^, of a calibre of 20 and 22 Fr. respec- 
tively. Slight organic contraction at triangular liga- 
ment. Meatus exceptionally large. Dilating urethro- 
tomy and systematic dilation for two months, with 
urgent advice to have dilation practiced occasionally 
for an indefinite time. Re-examination in the winter 
of 1891 showed some recontraction in deep urethra but 
none in the anterior portion of the canal. Gleet still 
persists slightly. 

Case XXII. Operated in January, 1890. Gleet of 
seven years' standing with vesical irritability. Strictures 
at 1I/2 and 3 inches respectively. Meatus amply large. 
Dilating urethrotomy. Re-examination in January, 
1892. The first stricture was found to have recon- 
tracted slightly and was again cut. The second stric- 
ture remained cured. Gleet still somewhat trouble- 
some. 

Case XXIII. This case presented itself for re- 
examination within a week. I have no notes of the 
operation, but recall having cut several penile strictures 
over four years ago (the patient says that three were 
cut). On re-examination I failed to find the slightest 
recontraction. This man was a dissolute dispensary 
patient, and I confess that I was surprised to find no 
recurrence of his strictures. 

Case XXIV. Operated early in 1890. Contraction 
at meatus and at a depth of 4 inches. Meatotomy and 
dilating urethrotomy. Re-examination December, 1891, 
showed recontraction, and a second operation was done. 

Case XXV. Operated in January, 1891. Meatus 
contracted. Stricture just within meatus and a second 
at 3X inches. The latter admitted only a 15 Fr. 
Meatotomy and dilating urethrotomy. There was quite 
a persistent curvature of the penis in this case, which 



238 STRICTURE OF THE URETHRA. 

lasted some six months after the operation. Re-exami- 
nation in April, 1892.. showed no recontraction. 

Other cases have been re-examined at variable 
intervals after operation, but the time which has elapsed 
has been too short to be of any value. It is obvious 
that the element of coincidence often enters into such 
observations, especially as influencing the percentage 
of cures. The entire number operated upon would be 
necessary to determine this. Even a short list of re- 
examinations, however, is sufficient testimony as to the 
radical character of the operation, even though only a 
few cases have been permanently cured. 

The following case, reported by Dr. Stuart Eld- 
ridge, of Yokohama, Japan, has a very pertinent bear- 
ing upon the prospect of a cure of stricture by ure- 
throtomy:* 

"W. L. Anatire, of England, was admitted to the 
General Hospital of Yokohama, Japan, December 31, 
1874, suffering from syphilitic rheumatism, urethral 
stricture and urinary fistulae. February 14, 1875, I 
joined the staff of the hospital, and found the man an 
inmate. The history of the case, so far as the stricture 
was concerned, was as follows: 

L. had suffered from stricture, the result of a severe 
clap, for some eight or nine years, during which time he 
had led a very dissipated life, and had repeated attacks 
of gonorrhoea. In the latter part of 1870, or the begin- 
ning of 187 1, he had been operated upon by external 
perineal urethrotomy with temporary relief, but had 
almost entirely neglected the after-treatment of his 
case, only occasionally and at long intervals passing a 
very small catheter when retention occurred or seemed 
imminent. The fistula at present existing was followed 
by the formation of a second fistula near the root of 
the penis. The constitutional condition of the patient 

* Vide Otis on Stricture, p. 353. 



CASES SHOWING RESULTS OF DILATING URETHROTOMY. 239 

was such that I attempted no active measures until 
May, 1875, when the status of the patient was as fol- 
lows: The urine was passed by the meatus in an inter- 
mittent and very small stream of perhaps one millimeter 
in diameter, by far the greater quantity flowing from 
two fistulous openings. One, the larger, nearly on the 
perineal raphe, midway between the scrotum and anus; 
the other, one centimeter to the left of the peno-scrotal 
junction. Both fistulae seemed to diverge from a com- 
mon sinus, though I was unable to pass an instrument 
into the urethra through either. 

To external manipulation the whole urethra was 
excessively knotted and indurated, the thickening and 
hardening being greatest in the proximal half of the pen- 
ile portion. Examination of the urethra by bulb-sounds 
revealed a hard and insensitive stricture seven centi- 
meters from the meatus, the contraction being seem- 
ingly about three centimeters in length, although, as 
with the most careful manipulation it would admit noth- 
ing larger than a bougie of four and one half millime- 
ters circumference, the determination of its proximal 
limit was uncertain. A false passage was detected, 
beginning a little more than two centimeters within the 
meatus, upon the right side of the urethral roof and 
to a depth of five centimeters, this having probably 
resulted from rough or drunken attempts at catheteriz- 
ation, and the entanglement of the instrument in the 
fossa navicularis. The whole urethra anterior to the 
stricture was rough and nodular, while that portion of 
the mucous membrane nearest" to the face of the con- 
traction was distinctly sacculated at several points. 
May 18, 1875, after full doses of quinine for forty-eight 
hours, the patient was etherized, Dr. E. Massais assist- 
ing; the meatus, of which the calibre was fifteen milli- 
meters circumference, was freely incised and with great 
difficulty Holt's instrument, guarded by a Maisonneuve 



24O STRICTURE OF THE URETHRA. 

conductor, was passed through the stricture, until firmly 
arrested about the bulbo-membranous junction. The 
instrument was then expanded to the utmost, although, 
from the fact that its point could not enter the bladder, 
the separation of that portion of the limbs which was 
engaged in the stricture was necessarily imperfect. Upon 
the withdrawal of the dilator its conductor was found to 
have curled up in the urethra posterior to the just ex- 
panded stricture, and examination detected a second 
stricture of about the same calibre as the first about 
thirteen centimeters from the meatus, or in the lower 
bulbous portion. The Holt was then with but little dif- 
ficulty passed into the bladder and expanded, but only 
by the use of considerable force, to twenty-four milli- 
meters circumference. 

A conical steel bougie, twenty and one-half milli- 
meters circumference, was then passed with ease 
through the whole length of the urethra. As L. had 
been unable to feel the sudden yielding caused by 
rupture, and almost no hemorrhage followed upon this 
double operation, I was inclined to think that dilatation, 
not divulsion, had taken place, and had I been pro- 
vided with a satisfactory instrument I should have 
performed internal urethrotomy at once. No unpleas- 
ant symptoms followed the operation, and at the 
expiration of a week I was able to pass a bougie of 
sixteen millimeters circumference without difficulty, 
though recontraction to the extent of at least four 
millimeters of circumference had evidently occurred. 
The sixteen millimeter bougie was passed six times at 
intervals of a week, when the fistulae, having healed, 
the patient was furnished with a bougie No. 10 English, 
and with most careful instructions as to the future use 
of the instrument; discharged from hospital. 

September 6, 1875, L* was re-admitted, suffering as 
before from syphilitic rheumatism, and evidently 



CASES SHOWING RESULTS OF DILATING URETHROTOMY. 24 1 

cirrhotic liver, and with both casts pus and albumen 
in his urine. On inquiry it was found that he had been 
drinking freely, had suffered from an acute gonorrhoea 
during the month of August, had entirely neglected the 
use of the bougie, and that the stricture or strictures 
had recontracted until the urine at times passed only 
guttatwi, and the fistulae in the perineum had partly 
re-opened. Shortly after admission retention occurred, 
and after unavailing attempts to pass a catheter by Dr. 
Massais, I aspirated above the pubes, and a few hours 
later succeeded in passing a filiform flexible catheter. 
As about this time the urine began to pass freely by 
the fistula, catheterization was performed but a few 
times. Little attention was given the stricture until 
the following December, when, suffering from excoria- 
tion and neuralgic pain, the patient begged for a second 
operation, to which, with some reluctance, I consented, 
and determined to perform internal urethrotomy, 
believing, as I do, that under the circumstances of the 
case, this operation is little, if at all, more dangerous 
than repeated, and probably useless attempts at gradual 
dilatation. The danger of any operation in his condi- 
tion was fully explained to the patient, but he persisted 
in demanding relief. Twenty mimims per diem of tr. 
ferri chloridi were administered for a week, and during 
the forty-eight hours preceding the operation one 
hundred grains of quinine were given. December 20, 
1875, Dr. A. Goertz of Yokohama assisting, ether was 
administered, and an examination made showing that 
the anterior stricture had contracted to a circumference 
of seven and one-half millimeters, while the bulbar 
stricture would admit but a filiform whalebone guide. 
Holt's dilator having been, by the exercise of con- 
siderable pressure, passed along the guide into the 
bladder by means of a tunneled point, was expanded 

to twenty-seven millimeters circumference. Very 

16 



242 STRICTURE OF THE URETHRA. 

trifling haemorrhage followed, as had been the case at 
the first operation. An estimate of the calibre of the 
urethra about the anterior portion of the bulb, which 
was the only part of the canal which was approximately 
healthy, having been made by the use of the urethra 
meter, the Otis urethrotome was introduced upon a 
guide, expanded to twenty-nine mm. in circumference, 
the estimated normal caliber, and both strictures 
incised from behind forward upon the floor of the 
urethra. A conical steel sound, 30 mm. in circum- 
ference, was then passed into the bladder without diffi- 
culty, and 10 grains of quinine administered before the 
patient left the table. The operation was followed by 
a sharp attack of urethral fever, with almost total sup- 
pression of urine for fourteen hours, but by free admin- 
istration of quinine, dry cupping over the kidneys and 
hot water, the condition of the patient was satisfactory 
by noon of December 22d. A week after the operation 
a conical steel sound 30 mm. in circumference was 
easily passed, and afterwards at intervals of a week 
until it had been used five times in all, not counting the 
insertion on the day of operation. The fistula rapidly 
closed, and the neuralgic pain did not recur; but the 
general condition of the patient became so bad that, as 
it seemed certain that some improvement in the 
urethral caliber would outlast the life of the patient, I 
felt that each use of the instrument, in view of the still 
diseased condition of the kidneys was attended with 
danger, and therefore the use of the bougie was given 
up. July 16, 1877, although the patient was in most 
wretched condition, he was discharged to the care of 
his friends for repeated violations of the hospital dis- 
cipline. He was re-admitted October 18, 1877, in a state 
that promised speedy death. Contrary to all expecta- 
tions, however, he lived until June 1, 1878, when he 
succumbed to syphilitic ulceration of the larynx. 



CASES SHOWING RESULTS OF DILATING URETHROTOMY. 243 



H £ 



From the time of the operation of December 20, 
1875, the patient made no 
complaint whatever as to 
the urinary organs. He 
occasionally amused him- 
self by the passage of a 
flexible bougie, No. 7 
English, but by his own 
statement there never ap- 
peared to be the slightest 
necessity for so doing. 
With the exception of the 
first passages of sounds 
following the operation, 
I am certain that nothing 
larger than No. 7 English 
entered the urethra from 
the time of the urethro- 
tomy until after death. 

Post mortem exami- 
nation, made June 1, 1878, 
revealed among other le- 
sious, fatty degeneration 
of the kidneys and cir- 
rhosis of the liver, while 
the immediate cause of 
death was found to be 
necrosis of the larynx, 
presumably syphilitic. 
The penis and bladder 
were removed intact, save 
by the displacement of the 
skin, and on examination 
the urethra was found Fi &- 6 ? 

to admit, through its whole 
length, a bougie of twenty-five mm. in circumference. 




244 STRICTURE OF THE URETHRA. 

Upon examination of the preparation when slit up 
along the floor of the urethra, there appears a little 
more than two centimeters from the meatus, and upon 
the right side of the roof of the canal, a smooth, flexible 
and elastic, but perhaps cicatricial surface, about eight 
m. m. in length by four m. m. in breadth, slightly 
depressed below the level of the general surface. This 
I take to be the remains of the fossa navicularis, and 
the closed entrance of the false passage encountered at 
the operation. (See Fig. 67 at point a.) Six and one- 
half centimeters from the meatus, and nearly in 
the median line of the urethral roof, there is a small 
bridle of soft and elastic covering in a false passage of 
two mm. in length (6) . Two centimeters posterior to 
this, in the median line of the roof of the canal, is a 
small, irregular, but soft, distensible cicatrix about five 
mm. in length by two mm, in breadth (c) while extend- 
ing backward from a point on the urethral floor oppo- 
site to that just mentioned, is a fine linear cicatrix of 
about one and a half centimeters in length (d) . I 
believe these cicatrices to have been the result — the 
former of divulsion, the latter of internal urethrotomy. 
At the bulbo-membranous junction there is an oval 
depression (e) covered with a smooth, elastic, soft mem- 
brane, which I take to have been the urethral mouth of 
the sinus which formerly existed, the more so as a 
probe passed from behind forward upon this depression, 
enters a sac of two mm. in depth at the anterior 
extremity of the surface alluded to. There is also in 
the membranous portion a false passage of five mm. in 
length, the bridge of tissue which covers it being soft 
and yielding. 

Most careful examination of the specimen while 
fresh failed to discover the slightest pathological con- 
striction at any point, while neither thickening nor 
induration could be detected by most painstaking 



EXTERNAL URETHROTOMY. 245 

search. The points alluded to above as presumably 
occupied by cicatrical tissue, were only distinguishable 
as such by their superior smoothness and the apparent 
absence of glandular structure when examined in sitti 
under a low power. At the former location of the 
bulbar stricture I was entirely unable to identify the 
scars either of the old external operation or of the 
later internal incision. 

The bridges of tissue constituting the false pass- 
sages b and f seemed equally soft and elastic with the 
rest of the mucous membrane, and certainly did not in 
the least diminish the urethral caliber. I should say 
that the evidence as to external perineal urethrotomy 
having been performed, is solely the statement of the 
patient, as the asserted locality of the cicatrix of that 
operation was involved in the opening of the perineal 
fistulse. I see, however, no reason to doubt that such 
an operation had been performed. * The case, taken in 
all its bearings, seems to go far toward proving the 
permanent curability of urethral stricture, even under 
the most unfavorable circumstances, providing that a 
free incision of the contractions is made and they be kept 
open for a very short time. Considering the facts above 
stated, a double, tight, cartilaginous stricture, exceed- 
ingly resilient, as shown by the failure to divulse, and 
by its speedy return after large distension, to which was 
added the traumatic complication of a previous perineal 
section, the bad general health and habits of the 
patient, together with the trifling amount of treatment 
given after the internal urethrotomy of December 20, 
1875, ^ * s evident that if, under such circumstances so 
nearly perfect a result is to be obtained by intelligent 
urethrotomy, the problem of the permanent cure of 
stricture may be deemed as solved." 

EXTERNAL URETHROTOMY. 

External Urethrotomy or Perineal Section may be 



24b STRICTURE OF THE URETHTA. 

divided for description into two varieties of operation, 
which, although involving the same structures, differ 
very markedly as regards their prognosis and facility 
of performance. They are termed perineal section 
with a guide and perineal section without a guide. 

Perineal section with a guide is the simpler and 
safer of these operations, but is adapted only to stric- 
tures which are permeable to the passage of instru- 
ments. The best procedure is known as Syme's opera- 
tion of external urethrotomy . The instruments neces- 
sary for operation are a staff with a central groove, a 
silver catheter of a caliber of 7 or 8 English, a sharp- 
pointed scalpel of moderate size, and a strong, broad 
grooved director. The required size of the guide or 
staff necessarily varies according to the caliber of the 
stricture. It may be grooved along its entire length 
or only along its convexity. Syme's staff has a shoul- 
der which impinges upon the anterior surface of the 
stricture, the groove in the convexity of the instrument 
beginning just at this point. If false passages exist in 
the canal a grooved hollow staff may be used. The 
successful passage of the instrument into the bladder 
being indicated by the flow of urine. 

Operation. The patient, having been anaesthetized, is 
put in the lithotomy position upon his back with the feet 
hands fastened together, wiih lithotomy anklets or 
ordinary roller bandages, the staff or guide is passed 
through the stricture into the bladder. The perineum 
should be scrubbed thoroughly and bathed with bichlor- 
ide solution t (H) • The operator, seated in front of the 
patient, now enters his scalpel with the cutting edge of 
the blade upwards, into the raphe of the perineum, a 
^ to ^ of an inch in front of the anus; an upward 
dissection of about an inch and a half is now made 
until the urethra is exposed, when the knife is made to 
enter the groove of the staff behind the stricture, 



EXTERNAL URETHROTOMY, 247 

after which the latter is thoroughly divided from behind 
forwards. The staff is now withdrawn and a good 
sized sound passed into the bladder to demonstrate 
that the canal is perfectly free. A soft catheter or the 
silver catheter before mentioned should now be passed 
into the bladder and tied in for twenty-four hours. 
There are several varieties of drainage tubes which 
are excellent substitutes for the catheter. At the end 
of a week or ten days gradual dilation must be com- 
menced, sounds being introduced every second day. 
The urine escapes by the perineal wound for some little 
time, but healing gradually occurs and the urine finally 
flows through its normal channel. Fistula is a rare 
result; sooner or later the track of the wound closes 
spontaneously. In very rare instances incurable fistula 
may result. 

The rules for our guidance in the operation as 
outlined by Syme are essentially -as follows: 

1. Be positive that the staff or guide has really 
penetrated the stricture and entered the bladder, this 
caution being especially necessary if false passages 
exist. 

2. Take care not to deviate the incision from the 
median line. In this location a sort of septum exists 
even in the deep perineal tissues. As long as the incis- 
ion does not deviate from this line there is little or no 
danger of injuring any vessel of considerable size. The 
principal vessel which is in danger is the artery of the 
bulb, but this need not be cut if the incision is carefully 
made in the raphe. 

3. Keep the edge of the knife upwards to avoid 
opening the posterior layer of the deep fascia of the 
perineum, with consequent danger of infiltration of 
urine into the pelvis with serious inflammation, and 
perhaps gangrene of cellular tissue. 

4. Insert the point of the knife posterior to the 



248 STRICTURE OF THE URETHRA. 

stricture and incise it by cutting from before backwards 
in the groove of the guide. 

5. There is sometimes considerable trouble in pass- 
ing an instrument into the bladder after the stricture 
has been cut. This may be obviated by inserting a 
director with a broad groove into the posterior portion 
of the urethra after the stricture has been divided and 
before the withdrawal of the staff. The grooved direc- 
tor is turned upwards in such a manner that as the 
sound or catheter is passed through the canal its point 
is directed past the incision into the bladder. When 
the stricture is multiple, the deepest one is generally 
the narrowest and toughest, and has to be incised, the 
other and slighter strictures being allowed to remain 
for treatment by dilatation. When, however, the stric- 
tures are very near together, they should be divided by 
one incision. 

In cases in which it is difficult to insert the ordi- 
nary grooved staff a filiform bougie may be passed into 
the bladder and Thompson's dilator threaded upon it. 
With this instrument the stricture is expanded until it 
will readily admit the staff. A tunneled staff may 
however be used, being forced into the bladder over 
the filiform as a guide. 

Reginald Harrison* has within a few years prac- 
ticed and indorsed a combination of internal and 
external urethrotomy. This operation consists of the 
performance of ordinary urethrotomy, after which a 
staff with a broad groove is passed into the bladder, 
and with it as a guide the perineum is punctured to an 
extent sufficient to permit a large tube to be introduced 
into the bladder. The object of the latter procedure 
is to prevent severe urinary fever by facilitating drain- 
age. Prof. Keyes practices this method of perineal 
puncture in all of his cases of suprapubic section, and 

* Brit. Med. Jour., July 18, l885. 



EXTERNAL URETHROTOMY. 249 

commends it very highly. He condemns any form of 
deep internal urethrotomy, excepting the Harrison 
combined method. 

External urethrotomy or perineal section without a 
guide, is one of the most troublesome and formidable 
operations of surgical practice. Some of the most 
skillful surgeons who have attempted the operation 
have failed in its accomplishment. Others have suc- 
ceeded only after a bunglesome, tedious and prolonged 
search for the urethra. It is a very fortunate circum- 
stance that such operations are at the present time very 
rarely necessary of performance, for the reason that if 
the surgeon be patient and administers an anaesthetic 
he will be enabled sooner or later to pass an instru- 
ment through the stricture and into the bladder beyond 
it. No matter how small the instrument may be which 
has been introduced, it constitutes an accurate guide to 
the course of the urethra if the surgeon is careful in his 
manipulations. Once an instrument is passed (even if 
it be but a filiform bougie) into the bladder, the case is 
practically under control, as a tunneled staff can be 
threaded over it and pushed through the stricture, the 
operation being then completed as in the ordinary form 
of perineal section. The practicability of instrumenta- 
tion therefore determines the safety of the operation of 
perineal section. Cases • are certainly very rare in 
which the operation without a guide would be warrant- 
able, for a period of temporizing no matter how pro- 
longed, is better than proceeding at once to such serious 
measures as section without a guide. Electrolysis may 
be tried if all other means of penetrating the stricture 
fail. 

In considering the operation of perineal section 
without a guide we must admit that, although exceed- 
ingly rare, cases of practically impermeable stricture 
may be met with. These may be termed surgically 



25O STRICTURE OF THE URETHRA. 

impermeable. Complete obliteration of the urethra 
can only be produced by injury, or sloughing of the 
mucous membrane and corpus spongiosum from some 
cause. Even in cases in which fistulae exist with an 
old and indurated stricture, the urethra is rarely imper- 
vious to instruments and urine. It is conceivable, 
however, that it might become so as a consequence of 
the diversion of the urine from its normal channel by a 
fistula, providing some lesion of the mucous membrane 
had existed which was capable of furnishing inflam- 
matory exudation. 

Erichsen records a case which is very interesting as 
showing that the urethra will remain patent under the 
most adverse circumstances, as follows: 

Case. " In the first case in which I performed the 
perineal section, almost all the urine, had for twelve 
years been discharged through fistulous openings in the 
perineum and scrotum, and the principal portion 
escaped through a large hole on the inside of the left 
thigh, a few drops merely occasionally passing out by 
the lips of the urethra. No instrument had been passed 
for four years, though repeated attempts had been 
made by different surgeons. Being foiled in introducing 
a catheter into the bladder the first time, I tried on, 
kept the patient in the hospital two or three weeks 
attending to his constitutional condition, but without 
making any further effort. He was then placed under 
chloroform, when I succeeded in passing No. 1. The 
urethra was then dilated up to No. 5, beyond which no 
instrument could be passed, when the perineal section 
was performed. The patient made an excellent cure, 
the fistulous openings closing and the urine being dis- 
charged by the natural channel." 

It is nothing unusual for the surgeon to discover at 
the time he proceeds to make the perineal section, that 
anaesthesia will relax the parts, when an instrument of 



EXTERNAL URETHROTOMY. 25 1 

moderate size may be readily introduced. Whenever, 
therefore, such operations are determined upon, an 
attempt should be made to pass instruments after the 
patient has been anaesthetized, in the hope of either 
providing a guide for the cutting operation or paving 
the way to treatment by dilatation, the rule being that 
when a stricture is permeable to fluid it is not imper- 
meable to a bougie. It must still be acknowledged that 
there are occasionally exceptions in which the urethra 
has become so tortuous and contracted, and the tissues 
of the perineum so indurated by inflammatory deposit — 
perhaps occurring as a consequence of extravasation of 
urine — that no instrument can be passed through, 
although urination can be performed with some facility. 
In cases of this kind a perineal section without a guide 
may be necessary. 

Operations which are begun without a grooved 
guide or the insertion of a bougie to indicate the line 
of the urethra, may often be completed with a guide 
after the anterior surface of the stricture has been 
exposed, a filiform bougie being passed through the 
latter. 

Operation. There are two ways in which perineal 
section without a guide may be performed: (i) The 
urethra is opened in front, and the stricture is divided 
from before backwards. What is known as the Wheel- 
house operation is the best method for this procedure. 
(2) The urethra is opened posterior to the stricture, 
and the latter is divided from behind forwards. The 
first method is by far the preferable one, the classical 
procedure being the boutonniere or a button-hole opera- 
tion. A sound or catheter of moderate size, say from 
8 to 10 English, should be passed down to the face of 
the stricture. It is then turned around in such a man- 
ner that the point of the instrument projects in the 
perineum in front of the stricture. An incision about 



2^2 



STRICTURE OF THE URETHRA. 



an inch and a half long is now made directly down 
upon the point of the instrument until the urethra 
is exposed. A small incision is then made into the 
latter just in front of the stricture, and the sound 
hooked up into the upper angle of the wound. A liga- 
ture is passed through each side of the incision, and 
each ligature is given to an assistant. These, in con- 
junction with the hook-like action of the staff, serve to 
hold the lips of the wound apart, and to facilitate 
inspection and exploration of the stricture. A special 
angular hook-like staff is used by Wheelhouse in this 




Fig. 



Wheelhouse's Operation. 



Ligatures may with advantage be substituted for the retractors and an ordinary sound 
will serve quite as well as the special staff shown in the illustration. 

maneuver. After the haemorrhage has been checked, 
the opening through the stricture will usually be readily 
seen. A fine probe or small director is slipped into 
this, if possible, and a fine bladed tenotome is passed 
along the guide so as to divide the strictured tissue. 
Great pains should be taken to search for the orifice of 
the stricture, for if a filiform bougie or bristle can be 
passed through it the operation is greatly simplified, 
the danger of the operation being that the surgeon will 



EXTERNAL URETHROTOMY 253 

lose the urethra, and in his aimless efforts to find it 
severe or even fatal haemorrhage may be produced. I 
recall a case of this kind in which a very capable sur- 
geon experienced so much haemorrhage in the operation 
that the patient died within a few hours. In another 
case I completed an operation after an experienced 
surgeon had sought for the urethra for two hours and 
failed to find it. 

Should it be impossible to pass a guide through the 
stricture after its anterior surface has been exposed, 
the urethra may be opened up posterior to it and an 
attempt be made to pass a probe or even bougie from 
behind forwards. Failing in this, a dissection must be 
made from before backwards in the normal direction of 
the urethra. Personally, in a case of this kind, I should 
be inclined to suprapubic section and retrograde cathe- 
terism. This procedure has on one occasion been in- 
valuable to me. 

After the stricture has been freely divided, a good 
sized sound should be passed into the bladder to 
demonstrate that the passage is clear. The sound is 
then removed, and a catheter passed and tied in as in 
the operation with a guide. The sound should be 
passed at proper intervals, as after the ordinary opera- 
tion of perineal section. 

Instead of passing a catheter through the entire 
length of the urethra and allowing it to remain in the 
bladder after the operation of perineal section, Harri- 
son's method of perineal drainage is excellent. This 
consists in the passage of a large soft rubber catheter 
into the bladder via the wound in the perineum. This 
is tied in and allowed to drain into the urinal. It may 
be removed in two or three days. Such a drainage 
tube facilitates washing the bladder and the perineal 
wound with antiseptic solutions and prevents infection. 

Haemorrhage after perineal section may usually be 



254 STRICTURE OF THE URETHRA. 

controlled by pressure. If venous oozing be very free, 
the wound may be stuffed with styptic cotton. Irriga- 
tion with very hot water is often efficacious. When 
the bleeding is obstinate a petticoated or " shirted " 
canula may be introduced, as in bleeding after litho- 
tomy. In one case I found the following device to act 
very well: A stiff gum catheter was passed through an 
ordinary condom and into the bladder. The condom 
was then blown up by a small catheter introduced into 
the outer end, and tied firmly about the catheter left in 
the bladder so as to prevent the air escaping. By this 
device sufficient pressure was secured to stop the 
haemorrhage. A perineal crutch may become neces- 
sary. 

One word of caution to the operator may not be 
untimely. He should begin, if possible, his operation 
early in the day, and be sure and secure plenty of light. 
A dark day and a hurry have been fatal to not a few 
patients in the practice of different surgeons. 

ELECTROLYSIS. 

Inasmuch as the method of treatment of strictures 
by electrolysis has received enthusiastic support at the 
hands of surgeons of undoubted skill and ability, it is 
but just that where possible to obtain the necessary 
apparatus in cases of stricture which appear to demand 
immediate operation by external perineal section, an 
attempt should be made to penetrate the stricture by 
this method. If cautiously used electrolysis is not apt 
to do much, if any, injury, and should it fail, it will, in 
all probability, not enhance the dangers of the perineal 
operation which will subsequently become necessary. 
Electrolysis has certainly been of service in my hands 
in a limited number of cases. Of this more anon. 

SUBCUTANEOUS DIVISION OF STRICTURE. 

This operation has been suggested and practiced 



SUBCUTANEOUS DIVISION OF STRICTURE. 255 

by Dr. C. H. Mastin, of Mobile, Ala., as a revival of 
an old time and well nigh forgotten operation. In a 
paper published in 1886, this gentleman spoke of the 
operation as follows: " In the year 1872 I wrote a 
paper upon the result of my operations by this method, 
and since that date to the present, with an increased 
experience, I have seen no reasons to alter the views 
which were then expressed. I now claim nothing of 
originality for the operation, since it is based almost 
entirely upon the old la boutonniere ; the incision being 
very small, and made anterior to the stricture; then, a 
very small probe-pointed director or whalebone guide 
is passed along through the stricture, and a delicate 
tenotome incises its upper wall subcutaneously; the 
small wound in the integuments is closed by pin sutures 
and left to heal by primary union. Adhering to the 
maxim, "dilate where you can, cut where you cannot." 
I only resort to this operation in those cases where no 
catheter or guide can be made to traverse the urethra 
from the meatus to the bladder; cases which require 
some operation for the immediate evacuation of re- 
tained urine, and in which it is not possible for me to 
perform an internal urethrotomy. 

" The patient, duly prepared by opening the bowels 
freely with an enema and a hot hip bath given to tran- 
quilize the nervous system, is placed upon a table, then 
secured in the ordinary position for cystotomy and 
anaesthetized. I now pass down the urethra the tube of 
Benique, which is a plain silver tube open at both ends, 
about nine millimeters in diameter, and from six to 
eight inches in length; this tube protects the walls of 
the urethra, and puts on the stretch the face of the 
stricture. The tube is now filled with a bundle of small 
filiform whalebone probes, which are carefully passed 
down to the stricture; by trying first one and then 
another, it is possible that one may engage the opening 



256 STRICTURE OF THE URETHRA. 

and pass on into the stricture This being accom- 
plished, I remove the disengaged probes together with 
the tube, and after securing the probe in the bladder I 
pass over it a Wheelhouse staff which has been drilled 
through its end to answer the purpose of a Gouley staff, 
and carry it down to the stricture; it is now handed to 
the assistant, who holds it lightly, yet firmly, against the 
coarctation, whilst I open the urethra in the groove of 
the staff, making an incision about half an inch in 
length. I then draw outward the staff just sufficiently 
to enable me to find the whalebone probe as it passes 
through its end and on into the stricture; this I secure 
by passing a small blunt hook behind it, after which the 
staff is removed entirely from the urethra, and the 
distal end of the probe drawn out through the little 
wound which has been made; and now, over the probe 
I pass a little gorgeret; this has its blade directed 
upward, and being run along the probe, as its guide, it 
passes through the opening into the urethra, and then 
down the stricture, which is cut on its superior face. A 
catheter is now passed along the entire urethra into the 
bladder and the urine evacuated, after which I care- 
fully examine the site of the stricture with graduated 
metallic ball probes for the purpose of detecting any 
bands which, perchance, may remain; if found, they 
are divided by the retrograde urethrotome of Civiale, 
and the full caliber of the urethra restored. 

" In the event, however, that it is not found possi- 
ble to pass a whalebone probe in the first instance so 
as to gain command of the stricture before opening the 
urethra, I then pass either the staff of Wheelhouse, 
Gouley, or an ordinary staff of slight curve with deep 
groove, down to the face of the stricture and practice 
the Leeds operation, with the exception that I do not 
rip open the whole stricture; but having gotten the 
whalebone probe through the coarctation, I thread over 



SUBCUTANEOUS DIVISION OF STRICTURE. 257 

it the little gorgeret and incise it on its superior face, 
just as described in the instance where the probe was 
passed along the tube of Benique, always taking care 
to sever any and all bands which may remain. This 
opening simply serves the purpose of shortening the 
canal and bringing us nearer the obstruction; it fur- 
nishes us a passage of only some few lines in length in 
which to manipulate our instrument, in place of a canal 
of several inches in extent, as would be the case if the 
urethra had not been opened. I thus virtually per- 
formed an internal section; I do not rip open the whole 
coarctated canal and lay bare to the external wound 
the cavity of the urethra, but I leave it, so far as the 
stricture is in question, just in the same condition as an 
urethra upon which I had done an internal urethro- 
tomy. 

" In the absence of the little gorgeret, I have found 
a very narrow-bladed urethrotome of Maissonneuve, 
conducted by a small filiform bougie passed through the 
external opening and coiled within the bladder, to 
serve a most excellent purpose, provided the staff is 
grooved on its concavity so as to insure the incision 
being made upon the roof of the urethra. Such, in 
brief, is the method I have adopted of operating exter- 
nally, and find that it is easy of execution, and satis- 
factory in its results. 

" Having carefully divided any existing bands, and 
restored the lumen of the urethra, I then pass a sound 
into the urethra, and, after the slight oozing of blood 
has ceased, I wash the parts thoroughly with cold 
water, to which may be added either a chlorine or 
weak mercury solution for the purpose of cleansing and 
disinfecting the wound; now I close the wound accu- 
rately with two or three pin sutures, passed deep 
enough to engage the divided edges of the urethral 

canal, and, after coaptating the edges of the skin, I 

17 



258 STRICTURE OF THE URETHRA. 

encircle the pins with a flat thread in the form of the 
figure of 8; then the sound is removed, and its place 
occupied by a full-sized catheter passed down to the 
prostatic urethra, but not into the bladder. The patient 
is put in bed and kept on his side, with instructions to 
push the catheter into the bladder when he has a call 
to urinate, and always, so soon as the urine has been 
discharged, to withdraw the catheter sufficiently far to 
get it out of the bladder, but not beyond the stricture. 
This catheter is used for only twenty-four to thirty-six 
hours, just long enough to insure the protection of the 
wound from the passage of the urine until it has been 
in a measure glazed over, and the strictured portion 
softened up by the presence of the inlying catheter. 
On general principles I am opposed to the sonde a 
demeure or retained catheter, and for obvious reasons 
too patent to need mentioning here; but the sound or 
catheter, used as I suggest, answers all the purposes 
for which it is intended, and keeps the urine from the 
wound until it is sufficiently protected by a glaze which 
prevents the urine passing into the external incision. 
At the expiration of this time the catheter is dispensed 
with and the patient left to pass his urine at will. 
About the fourth, or at latest, the sixth day, I remove 
the pins, and do nothing more to the wound save keep 
up the dressing of lead water and opium — which is 
applied immediately after the operation — for two or 
three days longer. Now the patient is permitted to 
get up and stir about, and within eight or ten days he 
resumes his former vocations. The after attention is 
such as is usual in all operations for stricture, whether 
they be external or internal, viz., the systematic use of 
gradually increasing steel sounds until the maximum 
caliber attainable in the special urethra has been 
reached. 

" With this course judiciously pursued, I find that 



SUBCUTANEOUS DIVISION OF STRICTURE. 259 

I am able to discharge my patients perfectly healed 
within from eight to twelve days; and in not a single 
instance, out of some twenty-five to thirty operations, 
have I had to contend with any haemorrhage or the 
annoying complication of urinary fistulae. 

"The advantages to be derived from this operation 
are the short time of confinement for the patient, free- 
dom from haemorrhage, quick union by primary adhe- 
sion, and the small amount of resultant cicatricial tissue, 
which is always deposited in greater proportion the 
longer the healing process continues. The retained 
catheter for the first day or two does good rather than 
harm, since it protects the fresh incision from the toxic 
effects of the urine until it has become glazed over with 
lymph, and acts, at the onset, by pressure upon the 
divided stricture, compressing the vessels which have 
been divided and which might bleed after reaction; it 
also sustains the urethra as a splint, and prevents the 
stricture from reuniting until we have time to begin 
gradual and systematic dilatation with the steel sound. 
The comparative immunity from urethral fever which 
my patients have enjoyed after this operation, I feel 
certain, is due almost entirely to the use of the inlying 
catheter as I employ it. I do not desire to be under- 
stood that I advocate the use of a retained catheter 
throughout the entire confinement of the patient to 
bed, but that I use it for only the first twenty-four to 
thirty-six hours — just sufficiently long to permit the 
wound to glaze over with lymph, and model, as it were, 
the granulations by gentle pressure. 

"In examining the details of the last ten opera- 
tions which I have done by this method (all of them 
bad cases) , I find that they were enabled to get out 
and be around the city in the following order: three 
on the fourth day after the operation, one on the fifth 
day, two on the sixth, two on the seventh, one on the 



260 STRICTURE OF THE URETHRA. 

ninth, and one on the twelfth. The others recovered 
in about the same proportions. 

" I am not apprised if any other method of per- 
forming external urethrotomy has afforded like rapid 
results." 

I have had no experience with this operation, but 
it unquestionably has high endorsement in Dr. Mastin 
and is certainly worthy of more extended trial. Person- 
ally, however, I favor free external section and drainage 
as being freer from the danger of sepsis than the sub- 
cutaneous operation. 



CHAPTER XII 



ELECTROLYSIS OF URETHRAL STRICTURE. 

Within the last few years the attention of practical 
surgeons has been frequently called to the beneficial 
effects of the galvanic current in producing resolution 
and absorption of neoplastic and inflammatory forma- 
tions of various kinds. This process is ordinarily 
known as electrolysis, but properly speaking this term 
should be reserved for those operations which consist 
of the decomposition of morbid tissues into their primi- 
tive elements by means of the galvanic current. Pow- 
erful galvanic currents are accepted as producing more 
or less complete decomposition of tissue, the oxygen 
and acids contained in their composition being deter- 
mined toward the positive pole at the point where it is 
applied to the surface of the body, the alkalies and 
hydrogen passing in the opposite direction towards the 
negative pole, which may be represented by a needle in 
the case of electrolytic operation upon tumors, and by a 
metallic insulated bougie introduced into the urethra in 
the case of stricture. The electrolytic treatment of 
stricture has been adopted as a routine practice by Dr. 
Robert Newman, of New York City. This gentleman 
has claimed some extraordinary results, and has pub- 
lished a series of apparently striking cases in substan- 
tiation of his claims of the value of the method. Sev- 
eral other prominent surgeons have tried the method 
with a greater or less degree of success. The majority 
of authorities upon genito-urinary surgery, however, 

have not yet accepted the electrolytic treatment as 

261 



262 STRICTURE OF THE URETHRA. 

preferable or even equal to the measures of treatment 
that have already been outlined. Prof. Keyes, of New 
York, has tried the method in a series of cases, and has 
not been favorably impressed with it.* 

In speaking of the various methods of treatment of 
stricture, he says: " Time has judged the internal use 
of caustics and condemned them, while the same fate 
awaits electrolysis lately revived. My experience with 
it has been unfortunate."! 

The late Dr. David Prince, J of Jacksonville, 111., 
highly recommended the method. 

I have tried the method in a large number of cases, 
but have not yet become convinced of its value as com- 
pared with the methods generally in vogue, and I am 
satisfied that its efficacy has been greatly overrated. 
I am free to say, however, that I consider it somewhat 
illiberal to absolutely condemn electrolysis as a method 
of treatment for stricture, upon an experience so limited 
as that of most of those who have radically opposed it, the 
more especially, as has already been indicated, because 
the treatment has served me a very useful purpose in a few 
instances. It is conceivable that in the hands of one so 
expert as Dr. Newman, much more favorable results 
might be obtained than by those who are, comparatively 
speaking, novices in the use of electricity. On the 
other hand, however, much depends upon Newman's 
interpretation of the term cure. The enthusiasm of 
the hobby rider also deserves consideration; the sur- 
geon is too often apt to find only those results for which 
he is frantically seeking, and fails to see the other side 
of the case. 

The question naturally arises as to the true action 
of the galvanic current in the treatment of stricture; 

* Practical Electro-Therapeutics; ten cases of Organic Stricture treated by 
Electrolysis, New York Med. Jour., December, i87i. 

' Genito-Urinary Diseases, E. L. Keyes, p. 127. 

. Essay before Central Illinois District Med. Hoc, October i9, 1886. 



ELECTROLYSIS OF STRICTURE. 263 

i. e. is it, strictly speaking, electrolytic? Personally I 
believe that within the limits of safety electrolysis of 
stricture cannot be produced, but that a certain amount 
of stimulation and absorption over and above that which 
may be produced by the pressure of the electrical 
bougie per se is the true explanation of its action.* 
Considerable nicety of judgment is obviously required 
in the selection of cases, the strength of the current and 
the frequency of the treatments. 

In a lecture before the class of the Medico-Chiur- 
gical College of Philadelphia, Dr. Newman described 
the method of electrolysis as applied to strictures sub- 
stantially as follows:f "Electrolysis is the process of 
decomposing a compound body by electricity, it is a 
chemical decomposition, and as applied to strictures 
the action is a galvanic chemical absorption. Absorption 
in this instance consists of the conversion of the morbid 
tissues into other substances through molecular changes. 
It will therefore be seen that in the application of 
electrolysis to the treatment of strictures of the urethra, 
chemical decomposition and absorption are depended 
upon. Chemical tissue destruction is in no sense aimed 
at. Electrolysis may be used in different ways: If the 
current is weak, slow absorption will be produced; if 
strong, the absorption will be more rapid, and will 
destroy the tissues." It is denied that any destruction 
of tissue is produced in the electrolysis of stricture if 
properly performed and as Dr. Newman recommends. 
The patient is first examined, and the location of the 
stricture determined as under ordinary circumstances 
with the bougie a bottle. The various characters of the 
stricture are determined as far as possible. After 
having determined the number, caliber, condition and 
distance of the strictures which exist in the canal, the 

% Dr. Newman disclaims the pressure action of the electrode. 
f New England Medical Monthly, August i5, i887. 



264 



STRICTURE OF THE URETHRA. 



next step is to determine the patient's susceptibility to 
the electric current. A twenty cell galvanic battery is 
sufficiently powerful for the treatment of stricture. The 
patient may be placed in either the standing or recum- 
bent posture. The positive pole of the battery should 
be connected with a large flat sponge, and may be 
placed in the patient's hands or upon any portion of his 
body. (It is best in my opinion to place it over the 
sacrum as in the accompanying illustration.) If the 




Fig 69. Method of using Electrolysis in Stricture. {Prince.) 



patient be timid the positive electrode sponge may be 
fastened to the arm or anywhere else upon the body, or 
held in the hand. The negative pole is the one which 
is attached to the bougie electrode and used for the 
absorption of the stricture. This electrode having been 
placed at the seat of the stricture after the distance of 
the first stricture has been measured upon it, the plates 
of the battery are then immersed in the fluid. It is 



ELECTROLYSIS OF STRICTURE. 265 

better to begin with a weak current, one, three or five 
cells. 

The lubricant which is used for the bougie is an 
important point. Oil cannot be used for the reason 
that it is a non-conductor. The best substance is 
glycerine, as it is a ready conductor and acts almost 
equally well for the purpose of lubrication. 

It is necessary to be certain that the battery is in 
good condition, as any interference with the chemical 
action of the fluid or the conduction of the current is 
fatal to the success of the operation. Irregularity of 
the current may be produced by a defective condition 
of the battery or the instruments used, and may not 
only interfere with the success of the operation, but 
may produce injury. The methods of determining 
whether the battery is in condition are (i) testing by 
the sense of taste. This is done by holding one elec- 
trode in the hand and touching the other to the tongue 
or cheek. If the current is being generated and passing 
properly a metallic taste will be distinguished. (2) If 
the electrodes be touched together a spark will demon- 
strate that the current is passing. (3) A galvanometer 
or milliampere-meter may be attached to the battery, 
the former will demonstrate if the current is passing, 
the latter will not only demonstrate the passage of the 
current, but also its strength. (4) The simplest and 
best method is to immerse the two poles in water, the 
bubbling of hydrogen gas which appears at the negative 
pole demonstrates the passage of the current. 

The bougie electrode is gently pressed against the 
anterior surface of the stricture. The sensation im- 
parted to the hand which holds the bougie will demon- 
strate whether the current is acting satisfactorily or not. 
The bougie should loosen in the urethra and move 
slowly onwards under a slight pressure. It usually takes 
from one to three minutes for a stricture of moderately 



266 STRICTURE OF THE URETHRA. 

large caliber to yield. Each stricture is operated upon 
in succession until it is felt to give way, great care being 
taken to use no force in the operation. The electrode 
is finally felt to pass into the bladder. A succession of 
bougies of increasing size may be used if necessary. 
During the entire operation the instrument should be 
held loosely and gently in its place against the obstruc- 
tion, violent pressure or force being avoided. The 
bougie takes care of itself during its work, by the elec- 
trical power that its action involves, whereas extreme 
pressure will only defeat the object and performance of 
its application, and may produce serious danger from 
haemorrhage or even rupture of the urethra. The 
operation being completed, care should be taken to 
reduce the battery to O by gradually moving the switch 
back to the starting point cell by cell, and only one at a 
time, before the bougie is withdrawn. Anaesthetics are 
rarely necessary, as the operation is not particularly 
painful. Newman uses in some instances cocaine, 
chiefly for its moral effect rather than because of its 
anaesthetic powers. A simple form of battery is recom- 
mended for general use. Newman says upon this point 
in his lecture: 

" You will find at the instrument makers elaborate 
instruments, but while elaborate instruments look better 
and finer, you can perform electrolysis with a more 
simple and cheaper instrument just as well as with these 
elaborate ones, and these fine instruments cost too 
much. I advise you then to buy the cheapest good 
instrument you can for a beginning, and after you have 
familiarized yourself with its workings you may add to 
your armamentarium by procuring larger instruments 
with other attachments as your practice and fancy neces- 
sitates. The 20-cell battery with carbon and zinc ele- 
ments is sufficient for our purpose as well as for many 
uses in medical electricity. The elements should be 



ELECTROLYSIS OF STRICTURE. 26/ 

small in order to give more intensity and less quantity, 
which means that the current must not cauterize the sur- 
face, or cut and destroy tissue like the galvano-cautery, 
but must work, according to the power employed, within 
a certain radius of the pole in order to bring about 
decomposition. A steady current is essential, which, on 
increasing or decreasing the current, will produce no 
shocks from interruptions. The duration of each seance 
depends on the work to be done, and the pluck and 
endurance of the patient. It is not good to tax the 
patient's endurance too much or to do too much work. 
An average duration of a seance will last from five to 
ten minutes. Often two minutes will suffice, while in 
otber cases twenty minutes may be required; but, as a 
rule, I prefer short seances with weak currents and 
longer intervals. The interval between seances ought 
to be at least one week or longer. In former years I 
even advised intervals of four weeks, and I never 
regretted this extra precaution. 

" Pain should never be inflicted by the use of 
electrolysis, and it should not be applied when the 
urethra is in an acute, inflammatory or even in an 
irritable condition. I told you before to use weak cur- 
rents, and the question will arise, what do we understand 
by weak currents. The current should be measured 
like other therapeutic doses. There are many diffi- 
culties to accomplish this, because accurate instruments 
for such purposes are very expensive, and the exactness 
suffers by many outside influences which we cannot 
govern. For medical purposes it is established now to 
measure the current by an milliampere meter which you 
see here, and which I have used in my former experi- 
ment. An ampere is equivalent to the strength fur- 
nished by an electro-motive force of one volt, passing 
through a resistance equal to one ohm. One ohm is a 
unit of resistance; one volt is the unit of tension. For 



268 STRICTURE OF THE URETHRA. 

medical purposes we measure by milliamperes, and you 
see here the division on the dial of the instrument. 
For our purpose I have advised to use an electric cur- 
rent oi 2y 2 to 5 milliamperes. This is a weak current, 
which may be increased according to circumstances. 
The milliampere meter is sold now for a very low figure, 
and therefore each beginner should procure the instru- 
ment, which in addition to measurement will also be a 
sure indicator of the workings of the battery. In some 
of my former reports of cases I have indicated the 
strength of the current used by six cells, or from four 
to ten cells. This was done for the purpose of better 
popular understanding by the non-experts of electricity, 
and at the same time it did express a certain measure. 
I had measured and gauged the current of my battery 
so that each cell in average yielded one-half of one 
milliampere, hence a current from eight cells would be 
equivalent of four milliamperes." 

The electrodes for the operation are a matter of 
some importance. The positive electrode should con- 
sist of a handle with a large carbon plate covered with 
sponge, which the patient holds in his hand or upon 
some other cutaneous surface. Newman prefers to 
place it in the palm of the patient's hand, and recom- 
mends a large carbon so that the current which com- 
pletes the circuit of the battery at this point may be 
diffused over a large surface and through a greater 
external resistance, the effect being pleasanter to the 
patient than where a smaller electrode is used. The 
most important instrument is the galvanic bougie. 
This should be stiff, unyielding, and made of metal, 
thoroughly insulated by a finely polished layer of hard 
rubber, except at either end. The upper end of this 
electrode is to be connected by binding screws to the 
negative pole of the battery. The urethral extremity 
has a metallic bulb, usually silver plated, which is placed 



ELECTROLYSIS OF STRICTURE. 269 

against the stricture during the operation. Newman's 
electrode has a short curve in order that the operator 
may with certainty guide with his hand the progress 
of the instrument and adapt it to the curve of the 
urethra. During the operation the hand of the oper- 
ator must guide the instrument with certainty and 
delicacy with a scrupulous avoidance of force. The 
larger the instrument the less certainly can it be con- 
trolled. Straight, short bougies with acorn-shaped 
bulbs may be used for the pendulous urethra." 

It will be observed from the foregoing description 
of electrolysis as applied to stricture, that, while it is 
apparently a very simple procedure, there are certain 
details requiring most careful attention, and upon which 
the success of the operation depends. Undue force will 
certainly produce injury, and should the operator in his 
enthusiasm attempt to hasten matters by increasing the 
strength of the current an actual charring of the tissues 
is apt to result with the inevitable enhancement of the 
strictured condition of the canal. It is probable that 
much of the prejudice against the operation is due to 
inattention to the details of its proper performance. 

In one of his more recent papers Dr. Newman has 
formulated the important points of the operation as 
follows: 

1. "Begin the use of electrolysis carefully; do not 
cauterize, only absorb; in many cases the current of six 
cells will suffice. 

2. Regulate the power and current of electricity 
according to the susceptibility of the patient. 

3. Repeat seances in intervals not too frequent in 
succession. 

4. Do not grease the bougie with substances that 
are non-conductors, and would insulate. 

5. Wet your electrode sponges with hot water; 



27O STRICTURE OF THE URETHRA. 

keep the plates in the battery fluid only during the 
operation. 

6. Never use force with your bougie; never cause 
haemorrhage. 

7. Do not operate while the urethra is in an acute 
or even sub-acute inflammatory condition, or when it is 
too painful. 

8. Use your battery fluid weak. 

9. Never use two bougies in succession with elec- 
trolysis during one seance. 

10. Practice at first only one method by absorp- 
tion. " Weak currents; long intervals \" 

A work on "Linear Electrolysis" by Dr. J. A. Fort 
was submitted to the Parisian Academy of Medicine a 
few years ago, in which the author, who has a large pri- 
vate clinic in Paris, chiefly devoted to diseases of the urin- 
ary organs, points out the advantages that this new pro- 
cedure possesses over internal urethrotomy, dilatation 
and divulsion, which are employed for the cure of the 
stricture of the urethra. The author's claims are essen- 
tially as follows: Electrolysis is an operation abso- 
lutely inoffensive, whereas he considers that urethro- 
tomy is a dangerous operation, often giving rise to fatal 
accidents. The operation with the electrolyzer is per- 
formed without previous dilatation, or any other prepa- 
ratory treatment. It is performed without causing any 
pain, and in four or five minutes. Even the narrowest 
strictures may thus be operated upon at once, and the 
operation is never attended with haemorrhage nor 
followed by accidents. It requires no further treat- 
ment, and the patient may be allowed to follow his 
occupations without inconvenience. Relapses are 
extremely rare. This, however, does not accord with 
the experience of Dr. Lavaux, who also has a large 
clinic for diseases of the genito-urinary organs. At a 
subsequent meeting of the Academy of Medicine this 



ELECTROLYSIS OF STRICTURE. 27 1 

author read a note on the remote results of linear 
electrolysis in the treatment of urethral stricture. 
According to his experience, some of the patients were 
cured for a time only, and more frequently relapses 
were rapid. Of thirty-five cases operated on with the 
electrolyzer,the radical and permanent cure claimed by 
Fort has never been obtained. Dr. Lavaux, therefore, 
prefers rapid dilatation to all other methods in the 
treatment of stricture of the urethra. 

At a later meeting of the Academy of Medicine, 
Dr. Dujardin-Beaumetz presented, in the name of M. 
Fort, a patient affected with stricture of the oesophagus, 
which M. Fort had operated on, assisted by Dr. 
Brochin, the well-known surgeon, by his procedure of 
linear electrolysis. The stricture, which was operated 
upon the 16th of February, then measured five milli- 
meters in diameter, but when the patient was presented 
it measured fourteen millimeters. The patint, who 
arrived from the provinces, and who was dying from 
inanition, was scarcely able to swallow even a few drops 
of liquid, but since he submitted to the operation he is 
able to take all sorts of nourishment. On his arrival in 
Paris, on the 16th of February, he weighed 114 pounds. 
This was the first time that linear electrolysis had been 
applied for the cure of stricture of oesophagus. The 
success was considered complete. 

Regarding the so-called electrolytic method it is 
not difficult to comprehend how ones judgment may be 
perverted by the practical and brilliant demonstrations 
of the power of the electrolytic current. It is all very 
well to exhibit the manner in which a piece of meat 
can be destroyed by the galvanic current, but this 
experiment proves nothing as far as urethral stricture 
is concerned. Cut out the stricture tissue and expose 
it to the same current, and it too will be destroyed. To 
destroy this same tissue in its fortified position in the 



272 STRICTURE OF THE URETHRA. 

urethral walls is a very different matter. The adven- 
titious tissue is mingled with useful tissue, which if 
destroyed, is replaced by a denser stricture than ever; 
then too, the adventitious tissue is insulated, so to speak, 
by mucous membrane which must be preserved if we 
would not make a bad matter worse. True electrolysis 
then, within the limits of safety, cannot be brought to 
bear upon urethral stricture. The galvanic current — or 
rather its electrolytic power — has no selective action 
which enables it to separate the chaff from the wheat, 
i. e. to pick out and dissolve pathological formations 
while sparing the useful tissues. 

He would be wise indeed, who could determine 
the truth regarding the use of electricity in urethral 
stricture from the reported results which have appeared 
in medical literature. The changes have been rung by 
observers of widely different characters and degrees of 
credibility. The electrolytic monomaniac, the com- 
mercial electrician, the intolerant bigot, and the man 
who recognizes no difference between the galvanic and 
faradic currents, have all been heard from, with the 
result that many conscientious surgeons have thrown 
their bulbs and batteries into the dead-lumber room. 
It is easy to understand how Newman can claim so 
much for the electrolysis of stricture; it is not so easy 
to understand the absolute condemnation of the method 
by so broad and scientific a man as Keyes. 

To claim such extravagant results as does the 
Newman school is no more absurd than to assert that 
the method is absolutely valueless. We must recog- 
nize the fact that the galvanic current exerts definite 
physiological effects upon living tissue, healthy or 
morbid. Knowing these effects, and knowing the con- 
ditions present in stricture, no fair-minded man can 
deny the probability of definite results in practice, 
The term electrolysis is here, it seems to me, a very 



ELECTROLYSIS OF STRICTURE. 273 

unfortunate one. The method should be termed 
galvanism. 

I do not consider it practicable, within the limits of 
safety, as already stated, to bring the electrolytic action 
of the galvanic current to bear upon a urethral stric- 
ture, with the possible exception of flaps and bands 
which are ingrafted upon the stricture per se. 

We have in organic stricture several factors: 

1. The first and most important is a new growth 
of fibro-connective tissue; 

2. Young cells in the process of metamorphosis 
into fixed connective tissue; 

3. More or less cedematous infiltration; 

4. Hyperemia or congestion; 

5. Spasm; 

6. Flaps, bands and bridles, due to exudate within 
the lumen of the canal and binding its folds together. 
These are often traumatic, and due to clumsy instru- 
mentation. They are sometimes due to follicular 
atrophy. 

Of the conditions named, only the first is essential 
to stricture. The other factors I will term plus condi- 
tions of stricture. These plus conditions are variable 
in amount and frequency, but may all be present in any 
given case, and may be either transitory or permanent. 

When properly used, the galvanic current stimu- 
lates the circulation, stimulates the absorbents, and 
allays irritation and spasm In addition we have the 
mechanical effect of the bulb of the electrode. 

To put the case concisely, I will state my belief 
that galvanism, judiciously used, will often subtract the 
plus conditions of stricture and facilitate the penetra- 
tion of otherwise surgically impermeable strictures. 
Once these conditions are removed, electricity is no 
longer useful, and we must seek other means of relief. 
It may thus be seen that if these statements are true, 



274 STRICTURE OF THE URETHRA. 

the range of application of electricity is not wide. I 
do not believe it is ever curative of organic stricture, 
nor do I believe it is often of value in the pendulous 
urethra. Strictures of this portion of the canal are very 
likely to require urethrotomy; certain it is, to my mind, 
that electricity will rarely obviate the necessity for the 
operation. A case of deep stricture occasionally arises 
where electricity will relieve retention, and so facilitate 
subsequent dilatation as to be invaluable, but such 
cases are not frequent. Surgeons may report cases of im- 
permeable stricture in which electricity has succeeded 
after all else had failed, by the dozen; but there will 
still be those among us who believe that the man who 
sees so many impermeable contractions is either a 
paper surgeon, unworthy of belief, or his reported cases 
are simply impermeable to him. As I have previously 
stated, impermeability of stricture upon one end of the 
bougie sometimes means impermeability of brain upon 
the other. 

One word of caution regarding the claims of some 
of the conscientious perhaps, but certainly over enthu- 
siastic supporters of electrolysis, may not be out of 
place, viz.: It is to be remembered that the temporary 
removal of symptoms, and even the passage of a good 
sized sound, does not necessarily mean that a stricture 
has been cured. Let every electrolytic enthusiast use 
the Otis standard and apply it conscientiously to his 
reported cures, and it may reveal some very interesting 
though cold facts. 

In thus stating what I believe to be the merits of 
the "electrolytic," or, more properly speaking, the gal- 
vanic treatment of stricture, I have endeavored to 
present them fairly and without bias. 

As an illustration of the occasional value of the 
galvanic current, I will cite a very interesting case. F. 
M., a pitcher in a professional ball club, consulted me 



ELECTROLYSIS OF STRICTURE. 275 

for a deep stricture of many years standing. After 
some difficulty I succeeded in passing a filiform, and 
finally a No. i French bougie. At the end of two weeks 
I had only succeeded in passing No. 5 French. No 
improvement in the stream of urine occurred. The 
stricture, primarily irritable and presenting from the 
first the plus conditions of congestion and spasm to a 
marked degree, became so irritable that for the next 
two weeks I failed to pass any instrument whatever. 
As the patient was compelled to leave the city, I 
determined to try galvanism as a parting shot at the 
obstinate stricture. With a No. 2 bulb and 3 milliam- 
peres of current I succeeded in penetrating the stricture 
in less than three minutes. The patient immediately 
passed a stream of urine which, as he expressed it, was 
" the biggest he had seen for seven years." 

I subsequently tried to complete the cure by elec- 
tricity, and succeeded in passing bulbs a size or two 
larger, after which the stricture came to a standstill and 
was absolutely resistant to galvanism. Gradual dilata- 
tion was then substituted for galvanism, and the case 
progressed finely. In this case it seems to me that we 
have an illustration of the efficacy of galvanism in 
removing complicating conditions in organic stricture 
and its impotency as far as the stricture proper is con- 
cerned. 

It is probable that the majority of surgeons will be 
loth to depend upon electrolysis for the cure of stric- 
ture in lieu of other measures which have proved 
reliable in their hands, but the operation certainly 
merits a fair trial and some attention on the part of 
students and teachers of the subject of genito-urinary 
surgery. Unfortunately the surgeon will be compelled 
to experiment for himself before he can judge of the 
merits of the electrolytic method. 



CHAPTER XIII. 



COMPLICATIONS AND RESULTS OF STRIC- 
TURE. 

FALSE PASSAGES — RETENTION — INFILTRATION OF URINE — 

URINARY ABSCESS FISTULA — VESICAL CALCULUS — 

ENLARGED PROSTATE CYSTITIS — PYELITIS 

— EPIDIDYMITIS IMPOTENCE. 

False Passages are rare occurrences in the practice 
of surgeons who exhibit the necessary patience and 
gentleness in the introduction of instruments. They 
are rarely caused by the use of large instruments in the 
ordinary performance of dilatation, and they are cer- 
tainly very exceptionally produced by the use of other 
than metallic sounds and catheters. 

Forcible instrumentation was formerly occasionally 
practiced for the purpose of relieving retention. A 
catheter was passed down to the face of the stricture, 
and then forcibly crowded on in the direction of the 
bladder. Very rarely indeed did the instrument pass 
through the stricture. More often it was forced 
entirely beyond the urethral walls and passed along in 
the cellular tissue. Once in a while the operator suc- 
ceeded in reaching and evacuating the bladder. The 
almost inevitable result of such surgery was the fre- 
quent occurrence of false passages. When an instru- 
ment is passed in this manner it may enter an enlarged 
follicle of the urethra and produce rupture at that 
point. More frequently the instrument enters a pocket 
in the anterior surface of the stricture, the false pas- 
sage taking its point of departure at this spot. The 

276 



PLATE VI. 




Mj 






Formation of false passage in stricture. The bladder has finally been reached by the 

instrument, but the urethra has been missed altogether. 

{After Dittel.) 



FALSE PASSAGES. 277 

signs indicating the occurrence of this accident have 
already been enumerated. Plate VI shows a graphic rep- 
resentation of the manner of formation of false pas- 
sages. 

Treatment. When the surgeon realizes that a false 
passage has been made, he should practice strict non- 
interference for a couple of weeks, unless retention 
exists. Further attempts at instrumentation will only 
result in all probability in a chronically indurated con- 
dition of the false passage. There will at first be 
slight haemorrhage from the urethra, and within a few 
days more or less purulent discharge. As a rule the 
passage will be found to have closed within two or 
three weeks. It may, however, in spite of conservatism, 
become chronic. Such accidents as urinary (i. e. septic) 
fever, infiltration of urine, abscess and fistulae, are occa- 
sional results of accidents of this kind. 

In passing instruments in a canal in which a false 
passage is known to exist, great care should be taken 
.to avoid entering the instrument into it. The oftener 
such a passage is dilated, or even irritated, the longer 
will it persist, and it may become absolutely incurable 
if such manipulations be persisted in. The deviation 
in the direction of the instrument, the sensation im- 
parted to the hand, and the patient's own subjective 
sensations will usually indicate the position of the 
instrument in such cases. A careful study of the case 
is necessary to determine the location of the orifices of 
old false passages. As a rule, the instrument will 
engage in the orifice of a false passage much more 
easily than it will in that of the stricture, and the com- 
parative facility with which the instrument is passed 
into an abnormal channel may mislead the surgeon, 
giving him the idea that he is dilating the stricture. A 
false passage may sometimes be avoided when once its 
location is determined. It may be necessary, when an 



278 STRICTURE OF THE URETHRA. 

instrument has once been passed into it, to allow it to 
remain in situ, other and finer instruments being passed 
in the hope of engaging one in the orifice of the stricture 
proper. The expedient of filling the urethra with fili- 
form bougies is sometimes successful, one or more 
instruments finally passing the stricture. An excellent 
plan, and one which has been very useful to me, is to 
pass an endoscopic tube down to the face of the stric- 
ture, a filiform being passed through it and an attempt 
made to enter the proper channel; if necessary the tube 
may be filled with the filiforms When once an instru- 
ment is passed through the stricture it should be 
allowed to remain in situ, and the stricture either 
dilated to a moderate extent by a Thompson dilator 
slipped along a filiform guide, or the treatment by con- 
tinuous dilatation begun. If it is found to be impos- 
sible to pass instruments through the stricture and 
retention exists, an aspirator or trocar should be used, 
while attempts at instrumentation are still persisted in. 
The best operation for stricture complicated by 
false passages is the external perineal section with a 
guide. Should it be absolutely impossible to introduce 
a guide, it is necessary to operate without it. Elec- 
trolysis may be tried if it be practicable to do so. 

RETENTION OF URINE. 

Retention of urine is the most frequent complication 
occurring in the course of stricture of the urethra. In 
all cases of stricture of small caliber the patient is con- 
stantly menaced with the danger of practically complete 
closure of the urethra incidental to spasm or congestive 
and inflammatory infiltration — i. e. plus conditions — at 
the site of the lesion. The danger of the occurrence of 
this accident is greatly modified by the constitutional 
condition of the patient, his habits, and what is quite as 
important, the delicacy of the manipulations which are 



RETENTION OF URINE. 2JC) 

instituted for the exploration and cure of the disease. 
Chilling of the feet and legs, indulgence in alcoholics 
even to a moderate extent, over-eating and sexual 
excitement with or without gratification, are the most 
frequent exciting causes. As an illustration of the 
manner in which retention is brought about, we will 
suppose a case of stricture of small caliber. The 
patient — naturally of an irritable, nervous temperament, 
and perhaps debilitated — indulges in a prolonged spree 
in combination with more or less frequent sexual indis- 
cretions. He exposes himself also to cold and wet 
weather, and moves about more than is good for him. 
As a consequence of these things, within a few hours 
he finds that it is impossible for him to pass urine. 
Spasmodic contraction of the muscles of the deep 
urethra and of the cut-off muscle in combination with 
extreme congestion at the site of the stricture, is to be 
inferred in a case of this kind. On the other hand we 
will suppose that the patient aithfully follows direc- 
tions, but unfortunately the surgeon in his anxiety to 
relieve the stricture, exhibits undue haste and unneces- 
sary roughness of manipulation; in a short time inflam- 
mation and spasm at the site of the obstruction occur 
and retention of urine results. It is very rarely indeed 
that the progressive, gradual contraction of the stric- 
ture produces retention in the absence of some exciting 
cause such as those mentioned. 

When retention of urine becomes complete the 
bladder soon becomes distended to its utmost capacity, 
and perhaps yields to the pressure of the contained 
fluid until it fills a large portion of the abdomen, and as 
a result of this distension there is considerable pain and 
constitutional disturbance. Under such circumstances 
it becomes urgently necessary to speedily evacuate the 
bladder. If this be not done, overflow may occur after 
a time, or the urethra will yield posterior to the stric- 



280 STRICTURE OF THE URETHRA. 

ture with consequent extravasation of urine either in 
front of or behind the triangular ligament. As a conse- 
quence of the extravasation, gangrene of the cellular 
tissue with profound prostration, a typhoid condition 
and usually death will ensue if the extravasation be 
extensive, or in more fortunate cases an abscess may 
form which subsequently discharges and leaves a fistula. 
In long standing cases in which the bladder is dilated 
and sacculated, rupture of the bladder itself may pos- 
sibly occur with an inevitably fatal result. After an 
attack of retention the bladder is always left in a much 
worse condition than before, and perhaps may be left 
in a more or less acutely inflamed state. 

Treatment* It is well to avoid the passage of instru- 
ments at this time where it is possible to do so, as the 
contact of a catheter with the inflamed structures is apt 
to enhance the irritation and make a bad matter w r orse. 
Antispasmodics should be given and the patient placed 
in a full hot bath. Morphia maybe given by the mouth 
or hypodermically until the full narcotic effect of the 
drug is produced. One of the most popular remedies 
for retention of urine, particularly in stricture of the 
urethra, is the muriated tincture of iron. This may be 
given in doses of ten drops every hour or in larger doses 
less frequently repeated. In the slighter cases of reten- 
tion this remedy in combination with narcotics, hot 
baths and other simple auxiliary measures is said to be 
quite generally efficacious, as indeed it should be by vir- 
tue of the auxiliary treatment. As far as the iron alone 
is concerned, I have failed to note any definite effects 
from its use. Should these measures fail to relieve 
retention an attempt should be made to pass a small cath- 
eter. Contrary to' what might be expected, an instru- 
ment sometimes passes through a stricture more easily 
where retention of urine exists than under other circum- 
stances. This is probably because a slight degree of ab- 



RETENTION OF URINE. 28 1 

sorption of the indurated tissue occurs as a consequence 
of the inflammation. In addition, it is probable that 
the pressure behind the obstruction serves to stretch the 
stricture apart to a slight extent, thus facilitating the 
entrance of an instrument. If necessary an anaesthetic 
should be given. Attempts at catheterization are not 
complete until anaesthesia has been produced. The 
surgeon should never despair of being able to introduce 
a catheter until he has failed when the patient is under 
an anaesthetic. If a catheter cannot be introduced prim- 
arily a filiform bougie may possibly be passed. This 
should be left in the bladder for some little time, and if 
when it is withdrawn the urine does not flow — as it is 
very apt to do — a small catheter may usually be intro- 
duced. When once an instrument has been passed, the 
case is under control, and whether catheter or bougie 
has been introduced the instrument should be tied in 
the bladder. Leeches should now be applied to the 
perineum. 

Free catharsis by means of salines will usually ben- 
efit in a derivative manner. Derivation may also be 
produced by the hypodermic injection of pilocarpine. 

Should it be impossible to relieve the retention via 
the urethra it is wise to temporize by the employment 
of an aspirator in preference to instituting dangerous 
operations of a radical character. (Fig. 70). In by far the 
majority of cases the urine will flow by the natural chan- 
nel a short time after the distension of the bladder has 
been relieved by the aspirator. Should this not occur 
however, the aspirator may be again used, and if neces- 
sary a number of times, the surgeon meanwhile proceed- 
ing with his antiphlogistic and derivative measures and 
cautious and gentle attempts to pass an instrument. 
Should the surgeon be unable to see the patient fre- 
quently it might be well after the introduction of a fili- 
form bougie or small catheter to pass a tunneled Thomp- 



282 



STRICTURE OF THE URETHRA. 



son's dilator over it as a guide, the stricture being mod- 
erately stretched. Divulsion and internal urethrotomy 
are not to be recommended at this time as a rule. The 
passage of a catheter for the relief of retention should 




Fig. 70. Potain's Aspirator. 

usually be considered as the commencement of treat- 
ment by continuous dilatation. 

After retention has existed for some little time the 
urine may begin to flow. This is apt to deceive the 
surgeon and lead him to believe that the retention has 
become spontaneously relieved. The apparent relief of 
the retention, however, is due in most cases to overflow; 
the bladder having been distended to its utmost capa- 
city, the amount of urine over and above that which the 
viscus is capable of containing, is forced through the 
stricture and dribbles away. Palpation and percus- 
sion of the abdomen under such circumstances will dis- 
cover the bladder enormously distended. 

If retention be patiently treated in the manner that 
has been outlined it will rarely be necessary to resort to 
a radical operation for its relief. 

In lieu of aspiration the bladder may be punctured by 
a curved trocar passed through the rectal walls beyond 
the border of the prostate. The operation is done as 
follows: The rectum having been thoroughly cleared by 



TAPPING THE BLADDER. 



283 



an enema, the left index finger of the operator is to be 
passed up beyond the prostate body; the bladder will 
be felt fluctuating at this point unless the prostate is 
greatly enlarged — when it cannot be so felt the trocar 
should not be passed. With the left index ringer as a 
guide, a long curved trocar and canula are passed 
through the anterior 
wall of the rectum in- 
to the bladder. The 
puncture made in this 
fashion perforates the 
trigone, which is a tri- 
angular space at the 
base of the bladder 
bounded at its apex by 
the prostate and at its 
posterior angles by the 
orifices of the ureters. 
The recto-vesical pouch 
of peritoneum is re- 
flected back above this 
point and is consequent- Fig. 71. 

ly not in the Way Of the Showing proper points for Rectal and Suprapubic 
#-r»i • Puncture. {After Enchsen.) 

operation. 1 he semi- 
nal vesicles bound this triangular space upon each side 
and may be wounded if the instrument is deflected 
from the median line. (Fig. 71). 

A circumstance which is peculiarly favorable to rec- 
tal puncture is the fact that between the mucous mem- 
brane of the bladder and the floor of that viscus, and 
between the floor of the bladder and the anterior wall 
of the rectum, there is very little cellular tissue. After 
the bladder has been punctured the stylet should be 
withdrawn from the canula and the latter tied in for a 
few days or until the stricture is under control. The 
danger of this operation is comparatively slight if it be 




284 STRICTURE OF THE URETHRA. 

properly performed; pelvic inflammation and consequent 
abscess, infiltration of urine, and even peritonitis have 
nevertheless been known to result. Peritonitis, how- 
ever, cannot result excepting in cases of anatomical anom- 
aly in which the recto-vesical peritoneal pouch descends so 
low as to cover the entire bottom of the bladder as far as 
the prostate. Instances have been known in which such a 
pouch has been punctured with a fatal result. 

The bladder may be punctured above the pubes, 
in cases in which the prostate is so enlarged that the 
rectal operation cannot be performed, or in case the 
surgeon has not access to the aspirator or rectal canula, 
Infiltration of urine into the cellular tissue about this 
portion of the bladder, with abscess and perhaps a per- 
manent fistula are the principal dangers of the opera- 
tion. In certain cases of enlarged prostate, whether 
complicating stricture or not, drainage may be estab- 
lished either per rectum, or better, above the pubes and 
maintained for a considerable length of time. The 
point of election whenever puncture of the bladder with 
the trocar is necessary, is the trigonum vesicce, the only 
exception being, as already stated, in cases complicated 
by enlarged prostate. In ordinary cases of enlarged 
prostate, suprapubic tapping or preferably section is 
usually the operation of election. 

Forcible catheterization has been recommended for 
the relief of retention. It is very unsurgical and very 
dangerous. Such go-as-you-please operations can only 
be condemned, as the bladder can only be reached in 
this manner by the merest accident. Very seldom indeed 
will the stricture be entered by forcible instrumentation, 
the catheter reaching the bladder, if at all, through a 
false passage. 

Harrison's operation of opening the urethra behind 
the stricture may be performed in cases in which fre- 
quent attacks of retention have occurred, and the strict- 



TAPPING THE BLADDER. 285 

tire is known to be traumatic, or hard and tortuous. 
The urethra may be punctured and a tube passed into 
the bladder for the purpose of drainage, the stricture 
being left to be attended to subsequently, or the opera- 
tion may be completed as in the ordinary perineal sec- 
tion — with a guide if possible, without it if necessary. 
It is advisable however, to await the results of palliative 
treatment in the hope of getting a guide through after 
a time, the danger of retention being meantime done 
.way with by the drainage. 

Where practicable to do so, it is well to try electro- 
lysis in cases of obstinate retention and impassable 
stricture, before proceeding to cutting operations. 

In surgically impermeable stricture, with retention 
of urine, the urethra may be opened through the perin- 
eum behind the stricture at the apex of the prostate. 




Fig. 72. 
Cock's operation of tapping the Bladder via the Perineum and Prostate. 

{After Bryant. ) 

This operation was devised by Mr. Cock, of Guy's Hos- 
pital, London. As described by him, the operation is 
as follows: The patient being in the lithotomy posi- 
tion, the left forefinger of the operator is introduced 
into the rectum and the apex of the prostate felt for 
and carefully thereafter kept in mind. A double-edged 
scalpel is then plunged with a steady and bold stroke 
into the raphe of the perineum directly toward the tip 



286 STRICTURE OF THE URETHRA. 

of the forefinger which lies in the rectum, the incision, 
at the same time, being enlarged in the median line to 
the desired extent by an upward and downward move- 
ment of the scalpel. The wound begins below, at about 
half an inch from the anus. The finger being still kept 
in the rectum, after the membranous urethra is opened in 
front of the prostate, the knife is withdrawn and a 
probe-pointed director introduced through the wound 
into the urethra and passed into the bladder. The 
finger is then withdrawn from the rectum; the director 
is held in the left hand and a canula, or catheter, is 
slipped along the groove of the director into the blad- 
der, where it is retained as long as may be necessary. 

The interesting feature of this operation is the fact 
that subsequent to its performance, the previously im- 
permeable stricture sometimes becomes permeable, 
probably because the rest imposed by the deviation of 
the urine from the natural outlet, relieves those super- 
imposed conditions the occurrence of which, added to 
the previous organic contraction, has produced the 
retention. 

The urethra has been opened from the rectum, for 
the relief of retention, th*^ incision being made into the 
membranous urethra. A soft instrument is passed into 
the wound, and from behind forward through the 
stricture and out at the external meatus, the other end 
being carried into the bladder. Furneaux Jordan of 
Birmingham, England, is the sole advocate of this oper- 
ation, which, to say the least, is of doubtful utility and 
hardly to be practiced in preference to some of the other 
operations for the relief of retention. 

INFILTRATION OF URINE. 

Infiltration of urine is perhaps the most serious 
complication of stricture of the urethra. It may occur 
in any one of five ways: 



INFILTRATION OF URINE. 287 

i. As a consequence of rupture of the urethra or 
bladder incidental to prolonged retention. 

2. By rupture of the dilated and ulcerated point of 
the urethra behind the point of obstruction, from pro* 
longed and violent straining efforts at micturition. 

3. By laceration of the urethra due to the over- 
distension of the canal produced by the passage of 
large sounds. In this instance infiltration occurs at the 
next act of urination. 

4. Division, or rupture of the urethra, incidental 
to the operations of internal urethrotomy or divulsion. 

5. Burrowing of urine between the layers of the 
tissue about the margins of the wound produced by ex- 
ternal perineal section. 

Infiltration of urine occurs in three forms: 
(a) Escape and extravasation of urine into the cellu- 
lar tissue of the pelvis, as a consequence of rupture of a 
dilated, thinned and sacculated bladder. (6) Rupture 
of the urethra within the confines of the deep layer of 
the superficial fascia of the perineum or Buck's fascia. 
(c) Infiltration produced by rupture behind the trian- 
gular ligament, or deep perineal fascia. 

The most common method of extravasation of ttrine is 
the giving way of that portion of the urethra which is 
immediately behind the stricture. This structure, already 
thinned and dilated, becomes overdistended and even- 
tually ulceration occurs at some point, usually upon 
the floor of the canal. As a consequence of retention 
of urine or of straining efforts in micturition, a few drops 
of urine escape into the surrounding cellular tissue and 
an extension of the ulcerative process immediately 
begins, with perhaps more or less sloughing of the tis- 
sues. As a consequence, the trifling aperture in the 
urethral floor becomes enlarged, and in a short time 



288 STRICTURE OF THE URETHRA. 

the urine escapes in considerable quantity into the 
cellular tissue of the scrotum, perineum, groin and — if 
Buck's fascia gives way — the thighs. In some instances 
the dilated follicle in the urethra becomes acutely 
inflamed, as a consequence of which its duct becomes 
occluded. Within the follicle a drop of urine is retained 
with the products of decomposition and inflamma- 
tion. After the closure of its duct this little pseudo- 
cyst becomes distended with pus and the irritating pro- 
ducts of urinary decomposition; Under these circum- 
stances it is apt to give way, either into the urethra or 
externally. Should it give way externally, extravasa- 
tion of urine may not occur, the process remaining as a 
folliculitis, or if more extensive, a urethral phlegmon. 
The abscess may be quite extensive. If the contents of 
the dilated follicle escape back into the urethra, an 
opening is thus afforded to the passage of urine. Later 
on the follicle ruptures as a consequence of over-disten- 
sion, and abscess occurs. Fistulse may result from such 
abscesses. In some instances an abscess ruptures exter- 
nally and subsequently opens into the urethra. Under 
such circumstances serious extravasation of urine is not 
apt to occur, the entire tract of the fistula having become 
lined with a pseudo-membrane which protects the sur- 
rounding tissues from burrowing of the urine. In other 
instances rupture of the urethra occurs, with the form?, 
tion of an abscess or sloughing of the tissues; the pro- 
cess finally appears externally, and a fistulous opening 
into the urethra is thus immediately established. The 
slower the process of infiltration the more apt it is to be 
confined by inflammatory exudate, which acts in a con- 
servative manner by preventing serious infiltration. 

The slighter forms of infiltration of urine may 
occur in any portion of the urethra and produce follicu- 
litis, peri-urethral phlegmon, abscess and fistula. When 
general extravasation of urine occurs, the portion of 



INFILTRATION OF URINE. 289 

the canal that usually gives way is the membranous 
urethra between the layers of the triangular ligament. 
At this point the walls of the canal are rather weak, 
there being a lack of support by the tissues about it. 
It is at this point also, that dilatation and thinning are 
most apt to exist, the location of the obstructing stric- 
ture being most frequently at the bulbo-membranous 
junction. Strictures anterior to this point are more 
often of comparatively large caliber, and are not apt to 
lead to those conditions which predispose to or excite 
general extravasation. The infiltrated urine finds its 
way after a time through the anterior layer of the 
triangular ligament at the point where it is penetrated 
by the urethra. It is now beneath the deep layer of 
the superficial fascia of the perineum, i. e. within the 
confines of Buck 's fascia; this fascia, as long as it is 
intact, subsequently guides the course of the urine. 
This structure it will be remembered, is attached to the 
anterior layer of the triangular ligament in the peri- 
neum, and laterally to the rami of the ischia and pubes 
as far upwards as the pubic spine where it becomes 
continuous with the deep layer of the superficial fascia 
of the abdomen. This latter fascia in its turn is 
attached anteriorly along Poupart's ligament as far as 
the crest of the ilium. The infiltrated fluid, therefore, 
invariably takes a direction, first, forward into the 
perineum and scrotum, and second, upwards upon the 
genitalia and the anterior abdominal wall and outwards 
along the groin upon either side. Were it not for the 
limitation of the extravasation by Buck's fascia, the 
fluid would be governed by the force of gravity, and 
would pass backwards and downwards, extravasating 
about the rectum and down the thighs. Should Buck's 
fascia give way, the infiltrated urine may gravitate 
backwards, and may also appear laterally upon the 
thighs. Erichsen records a case in which the fascia 



2QO STRICTURE OF THE URETHRA. 

yielded to the pressure, and the urine gravitating back- 
wards gave rise to extensive sloughing in the ischio- 
rectal fossa and about the nates, denuding the rectum.* 

The effects of infiltration of urine are two, viz., gen- 
eral and local. The general symptoms are from the first, 
in some instances, of an asthenic and irritative character. 
Even in the strongest patients, infiltration is soon suc- 
ceeded by a condition of asthenia with typhoid symp- 
toms, low muttering delirium, dry brown tongue, sordes, 
and finally coma and death. If the treatment is unsuc- 
cessful in relieving the infiltration, in some cases in 
which the infiltration is limited in extent an abscess 
results with the same symptoms as are observed under 
ordinary circumstances, with the exception perhaps, 
that there is a more marked tendency to nervous pros- 
tration. The profoundly asthenic character of the con- 
stitutional manifestations of general and extensive 
extravasation of urine is quite remarkable, and can 
only be explained upon the assumptions that: 

i. The parts are very intimately associated with 
the sympathetic nervous system. 

2. There is produced as a consequence of urinary 
decomposition some peculiar toxic principle allied to 
ptomaines or leucomaines, which, when absorbed into 
the blood, profoundly depresses the nervous functions. 

3. There is superadded in the majority of cases the 
absorption of the ordinary products of putrefaction of 
tissue, i. e., septic infection. 

4. There exists a marked tendency to constitu- 
tional depression incidental to greater or less marked 
impairment of the functions of the kidneys and con- 
sequent chronic uraemia. 

These four elements in the production of severe, 
and in a large number of instances, fatal symptoms, 
should receive due consideration in all cases of the 

*Op. cit. vol. II, p. 877- 



INFILTRATION OF URINE. 2QI 

kind, as they constitute the most accurate criteria for 
our guidance in the treatment. 

The local effects of infiltration of urine are very- 
marked. It must be remembered that the results of 
infiltration of urine are not those of contact of the 
urine per se, but contact of urine which has become 
vitiated by decomposition and the addition of the pro- 
ducts of inflammation and putrefaction. Perfectly 
healthy urine has been shown to be harmless when 
injected into the cellular tissue. Professor Keyes has 
discussed the varying effects of healthy and morbid 
urine when injected into the tissues in a most thorough 
and scientific manner, and has studied the literature of 
the subject most exhaustively as will be seen by the 
following remarks which I have taken the liberty of 
quoting in full: "It is a property of decomposed 
ammoniacal urine to destroy the vitality of living tissue 
wherever it comes in contact with it, unprotected by 
epithelium. This property does not belong to limpid 
healthy urine. Menzel* demonstrated this fact experi- 
mentally. He first used acid urine, injecting it under 
the skin of a dog in quantities varying from a drachm 
to an ounce without any bad effect in several experi- 
ments. He dissected up the skin of a dog to the 
breadth of four inches, and injected eight ounces of 
healthy human urine in four different cases. The 
urine was also absorbed within four days in three of 
the cases, in the other healthy pus formed. He 
repeated these experiments in the ischio-rectal fossa 
without bad results in five cases. To test the opinion 
of Simon,f that the compression with distension of the 
tissues in urinous infiltration was the cause of gangrene, 
Menzel performed two experiments, injecting healthy 
urine into the tissues with such force as to raise a 

♦Wien. medicin. Woch., Nos. 8i-85, 1869, and N. Y. Med. Jour., 1871. 
f'Chirurgie der Nieren." 



292 STRICTURE OF THE URETHRA. 

tumor of the size of the foetal head, and then prevented 
the escape of the fluid through the wound by means of 
suture. The quantity injected amounted to about half 
a pint, but in both cases it was absorbed without evil 
result within three days. 

" The next experiment consisted in cutting down 
upon the urethra of a dog and sewing up the wound so 
as to obtain infiltration. At each angle of the wound a 
fistula formed, but there was no poisoning or extensive 
death of tissue. He repeated the same experiment, 
tying the glans penis so as to cause all the urine to 
flow into the wound. An immense tumor formed, 
which only subsided when the glans penis became gan- 
grenous and separated. The dog got well, with simply 
a fistula. In other similar cases he obtained the same 
results. 

From these experiments Menzel concluded: 
i. " That normal urine does not possess septic 
qualities, and does not produce gangrene by its chemi- 
cal properties. 

2. " That distension by infiltrated urine does not 
produce gangrene. 

3. That gangrene, when it does occur (on infiltra- 
tion of healthy urine), is caused by contusion or the 
accidental inoculation of septic matter. 

" Menzel next experimented with urine containing 
soda or potash. Urine so alkalinized proved innocu- 
ous; but urine rendered alkaline by ammoniacal fer- 
mentation he found to be exceedingly poisonous, and 
when injected, to cause large abscesses and cutaneous 
gangrene. He also injected putrid urine directly into 
the blood, and obtained symptoms of blood poisoning. 
He further adds the clinical experience of Professor 
Billroth in nine cases of infiltration. In one, the ure- 
thra was perforated by a catheter; in three, there was 
a crushing injury to the perineum; in another, lacera- 



INFILTRATION OF URINE. 293 

tion of the urethra by a splinter of bone from the 
pelvis; in the rest, rupture of the urethra behind a 
stricture. Death followed in four cases, in two of which 
there was stricture, and the urine probably ammoniacal 

" A most instructive scientific discussion as to the 
cause of the fermentation of urine is to be found in the 
admirable thesis of F. P. Guiard,* and many new and 
interesting facts about the toxic qualities of normal 
urine in Bouchard's admirable contribution to the sub- 
ject.! Bouchard experimented upon rabbits by inject- 
ing normal healthy urine into a vein. x\n injection of 
two to three drachms caused contraction of the pupils, 
shallow, hurried respiration, and finally death with 
reduction of temperature and of reflex activity. Bou- 
chard believes that in two days and four hours a man 
eliminates enough poison to destroy himself, were it 
properly applied. He finds diurnal urine to possess 
narcotic properties, the night urine to be less poisonous 
than the diurnal secretion, but to cause cramps and 
convulsions. He is still investigating this interesting 
subject. 

" But, notwithstanding all this, the fact remains 
that so far as the local death of tissue is concerned, 
while ammoniacal and putrid decomposing urine is 
deadly in its effect, healthy urine, in moderate quantity 
at least, is readily absorbed by the tissues, and does not 
lead to local inflammation or death of tissue. My 
house-surgeon, Dr. Partridge, made for me many 
experiments by injecting healthy urine, acid and alka- 
line, (not ammoniacal) into the subcutaneous tissues, 
using as much as sixty minims at a single injection. 
No abscess was ever caused by these injections; 
absorption was perfect. Feltz and RitterJ have injected 
enormous doses of urea into dogs without damage, 

*"La Transformation ammoniacal des Urines,'' These, Paris, 1883. 
tGazette Hebd., 1886, Vol. xxxiii, Nos. 13 and 14, pp. 205-221. 
iLa France Med:, May 11, 1878. 



294 STRICTURE OF THE URETHRA. 

unless some of the salts of ammonia are combined with 
the urea. There appears to be no normal ferment in 
the blood capable of transforming urea into ammoni- 
acal salts. Pasteur* overthrew Bastian's experiments, 
and showed that without bacteria urine does not 
decompose. Pasteur and Joubert,f repeating some of 
the experiments of Musculus, show that the soluble 
ferment produced by the latter from ammoniacal urine, 
which is capable of changing urea and water into car- 
bonate of ammonia, is the product of bacteria. P. 
Cazenave and Ch. Livon ligated a dog's prepuce, 
allowed the dog to die, tied the ureters and urethra, 
removed the bladder, and kept it exposed to air for 
several days at temperatures varying from 8o° to 122 
Fahr. The urine did not decompose, and no organisms 
appeared in it. 

" These results, experimental and clinical, corre- 
spond with daily experience as well as with my per- 
sonal experiments undertaken upon the human subject 
— since the evidence derived from dogs and rabbits has 
been doubted — to substantiate the fact that healthy 
urine, injected into the connective tissue without con- 
tusion of that tissue, is as capable of absorption as the 
blandest fluid. This is true, at least, when a small 
amount is used (?j) , a quantity certainly sufficient to 
establish that healthy urine, per se, is not destructive to 
human tissues. Muron, a pupil of Verneuil, stimulated 
seemingly by the results obtained by Menzel, performed 
a series of experiments by injecting urine under the 
skin of rabbits. His results corresponded closely to 
those reached by Menzel, only differing in one respect; 
for, while Menzel states that only urine in alkaline fer- 
mentation has destructive powers, Muron proved (upon 

*Comptes rendus de l'Acad. des Sciences, July 23, 1877, 

tJour. de Pharmacie et de Chimie, Sept., 1876, p. 206. 

"Dr. L. A. Stimson informs me that, in the winter of 1873, he saw Vulpian. in Paris, 
inject healthy human urine into the blood-vessels of dogs, in one case three and one-half 
ounces, without disagreeable result." — Keyes 



INFILTRATION OF URINE. 295 

rabbits) that urine, strongly acid, dense and full of salts, 
urates, etc., has the same powers to a less degree, 
attributable, he believes, to the density of the fluid 
injected, which by the law of osmosis attracts serum 
from the vessels instead of itself being absorbed into 
the latter; and again to the fact that urine, rich in 
urates, is apt to decompose quickly. Gosselin and A. 
Robin* conclude from experiments that acid normal 
urine, sp. gr. 1.023, * s innocuous when injected into 
rabbits, although it may kill if continuously injected for 
a number of days. 

"That Muron is incorrect in ascribing necessarily 
destructive properties to dense acid urine, rich in urates, 
I think must be granted. I obtained a specimen of 
urine from a child with acute inflammatory rheumatism. 
It was strongly acid, sp. gr. 1.040, and deposited, on 
cooling, a dense precipitate of pink urates which 
equaled one-fourth of the volume of* the liquid. A por- 
tion of this was taken a few hours after being passed, 
warmed until the urates dissolved, and injected by Dr. 
Partridge, of the Charity Hospital, into the subcuta- 
neous tissue of the arm in three patients, half a drachm 
being used in each case; absorption was immediate and 
perfect. Twenty-four hours after three other patients 
were similarly injected from the same specimen, with 
the same dose (?ss each) — only the urine was injected 
cold with the urates in precipitation. The bottle was 
shaken, and the fluid resembled pea soup. A little 
tenderness on pressure for a few hours marked the spot 
of the injection, but absorption was prompt and com- 
plete in each case without any suppuration. 

" Hence it may be affirmed that healthy urine does 
not, per se, kill tissue, unless that tissue be contused or 
inflamed (absorption thus prevented and urine allowed 
to decompose in situ) , and that, with infiltration relieved 

*" L'Urine ammoniacal et la Fievre urineuse," Paris, 1874. P- 39- 



2g6 STRICTURE OF THE URETHRA. 

by free incision, the prognosis is vastly better if the 
bladder were previously healthy. After urethrotomy 
and operations for stone, how rare is infiltration, when 
the urine is comparatively healthy and has a chance to 
escape, although it passes over a raw surface on its way 
out. The practical deduction from the above is to let 
out urine as soon as it has extravasated, and the 
chances are that serious gangrene may be averted 
unless the urine was strongly ammoniacal and decom- 
posed before its escape, which is, unhappily, too often 
the case."* 

I have on several occasions followed the same line 
of experimentation with healthy urine as that adopted 
by Professor Keyes, and have injected fresh urine into 
the cellular tissue of both man and animals, and have 
verified his observations as regards their innocuousness. 

The lines of analogy which may be drawn between 
the local and general effects of extravasated morbid 
urine and the results of inoculation of various animal 
poisons are very striking. The virus of certain veno- 
mous reptiles and insects, the poison of dissecting 
wounds, erysipelatous poison, the septic products of 
certain forms of inflammation, the poison of puerperal 
fever, and that of decomposing urine, are strikingly 
similar in both their local and constitutional effects. 
In the first place they are all markedly destructive of 
the vitality of cellular tissue. It would seem that as 
soon as any of these poisons come in contact with any 
of the areolar structures of the body, the vitality of 
their component cells is speedily depreciated or entirely 
destroyed, with effects varying from a moderate degree 
of cellular inflammation to severe and extensive slough- 
ing. There is but little difference to be observed 
between the local effects of any of these poisons when 
injected into the cellular tissue. It has been observed 

♦Revision of Van Buren and Keyes by E. L. Keye». 



INFILTRATION OF URINE. 297 

that the poison of the rattlesnake produces a double 
series of effects. In the first, instance it produces local 
inflammation, suppuration and sloughing, with infection 
of neighboring lymphatic glands and the production of 
abscess. These phenomena are precisely identical with 
the cellulitis produced by the inoculation of septic or 
erysipelatous poison. It produces in the second 
instance profound constitutional disturbance. In some 
cases the poison destroys the life of the individual 
before the local effects of its inoculation have had time 
to manifest themselves. In other cases the primary 
constitutional manifestations are survived and conse- 
quently general disturbances come on, their severity 
and character being determined by the nature of the 
local changes. The same description may be applied 
to the effects of any of the other poisons that have been 
mentioned, their effects varying according to the fol- 
lowing circumstances: 

1. The amount and virulency of the inoculated 
poison. 

2. The duration of exposure to infection. 

3. The inherent resisting power of the individual. 

4. His condition at the time of infection. 

5. The condition of his eliminative apparatus — this 
being a vital point, inasmuch as it determines not only 
the facility with which the system is able to resist the 
inroads of the poisonous material, but also the rapidity 
with which it is thrown off by the various emunctories. 

It is unnecessary to expatiate further upon this point, 
sufficient having been already said to call attention to 
the marked co-relation which exists between the effects 
of various animal poisons of very diverse origin, and 
probably also of very different chemical composition. 
The important relation which bacteria bear to the 
effects of infiltrated urine is now generally conceded. 

When urine is infiltrated into the structures of the 



298 STRICTURE OF THE URETHRA. 

perineum and about the genitals the effect of the irri- 
tant poison is immediately manifest wherever the areo- 
lar tissue is touched by the fluid. A diffuse cellulitis- is 
set up and the tissues are converted into dark, pultace- 
ous, stringy sloughs, mingled with fetid pus of a dark 
color, and decomposing ammoniacal urine. If the ure- 
thra gives way suddenly, the irritant fluid is forced into 
the tissues for some distance in and about the affected 
portion of the canal. Under these circumstances the 
destruction produced is very extensive. The scrotum 
may slough, leaving the testes absolutely bare. The 
patient is apt to die before this occurs, however, so that 
such an appearance is rare, excepting in individuals of 
exceptionally powerful constitutions. In some cases 
the extravasation occurs more slowly, as has been 
already indicated. A few drops of the irritant fluid 
escape from the canal through a small solution of con- 
tinuity in its coats; this gives rise to inflammation of a 
phlegmonous character in the tissues about the urethra, 
which limits for a certain time, and perhaps indefinitely, 
the progression of the extravasated fluid. This inflam- 
mation usually causes an abscess which may break inter- 
nally or externally, and may be followed either by gen- 
eral extravasation or by fistula. When the extravasa- 
tion is rapid and extensive the perineum becomes 
brawny, and finally boggy, the scrotum distended and 
cedematous, the parts presenting a dusky or purplish 
red color; the tissues speedily become of a greenish- 
black hue and lapse into a condition of gangrene. 

If the patient is able to resist the depressing effects 
of the resulting destruction of tissue, either through his 
inherent resisting power or as a consequence of imme- 
diate and successful local and general treatment, repair 
may be very active. The reparative power of these 
tissues is something remarkable, and is noted not only 
in these cases, but in cases of phlegmonous erysipelas 



INFILTRATION OF URINE. 299 

and cellulitis affecting this region. The extravasation 
rarely extends further than the groins and lower portion 
of the abdominal wall, but has been known to reach the 
level of the ribs before the death of the patient. When 
in the course of retention of urine the urethra gives way 
between the layers of the triangular ligament, a sense 
of relief is experienced by the patient, with a feeling as 
though the tissues had ruptured in the perineum, this 
being attended perhaps by more or less pain. The 
symptoms may be obscure for some little time; very 
Mttle swelling occurs, but in a few hours — or perhaps not 
for a day or two — a sense of heat, throbbing or lancin- 
ating pain and burning will be experienced in the pre- 
ineum; later on a boggy, diffuse, purplish-red swelling 
appears in the perineum and scrotum and extends for- 
ward very rapidly. 

When the infiltration takes place entirely behind 
the triangular ligament a similar sense of relief is 
experienced, but the symptoms are subsequently even 
more obscure. After a time — if the patient lives long 
enough — deep, throbbing pain will be experienced, and 
perhaps a swollen condition of the perineum may be 
detected. Examination per rectum may detect the 
boggy fluctuation characteristic of infiltration. In those 
cases of rupture posterior to the ligament the fluid is 
quite apt to burrow into the pelvis and about the rec- 
tum and prostate and destroy life without any positive 
external manifestations. The patient under such cir- 
cumstances sinks into a typhoid condition, succeeded 
by coma and death. 

As outlined by Professor Keyes,* the extravasa- 
tion may take any one of five directions, which are as 
follows: 

1. " It may when small in quantity get out of the 
urethra, but not penetrate Buck's fascia, in which case 

*Op. cit. p. i42. 



300 STRICTURE OF THE URETHRA. 

it may long remain confined to one spot in the per- 
ineum as a hard, rounded swelling. 

2. " It may find its way rapidly through the meshes 
of the corpus spongiosum and cause gangrene of that 
body, with sloughing of the glans penis, preceded by 
coldness and the appearance of a black spot upon the 
glans. 

3. " It may burrow inside of Buck's facia, but out- 
side of the corpus spongiosum, forming a fistula open- 
ing behind the glans penis or on the back of the penis 
near its root, a hard ridge marking the course of the 
fistula within Buck's fascia. 

4. " It may escape behind the triangular ligament 
into the cavity of the pelvis. 

5. "It may escape outside of the common fascia of 
the penis, in front of the triangular ligament; in which 
case it rapidly distends the perineum, the scrotum, and 
the connective subcutaneous tissue of the penis, and 
mounts up over the abdomen, and may also, more 
rarely, perforate the deeper layer of the superficial per- 
ineal fascia, and descend upon the thighs. 

"When extensive infiltration of this sort occurs, all 
the parts affected become cedematous; gases form in the 
connective tissue, causing emphysema, and making the 
tissues crackle when pressed by the finger. Dark spots 
soon appear, indicating gangrene, and extensive por- 
tions of tissue may slough away unless relief be promptly 
afforded. 

"The constitutional symptoms are those of shock. 
A chill usually occurs, followed by great depression, a 
cold, clammy skin, feeble, quick, irregular pulse, hurried 
respiration, furred tongue, complete anorexia, symp- 
toms of septicaemia and death. 

" When the urine escapes behind the triangular liga- 
ment, which it does more rarely, it infiltrates deeply 
around the prostate and rectum well back in the 



INFILTRATION OF URINE. 3OI 

perineum, around the bladder and up behind the pubis, 
forming abscess in the cellular tissue of the hypo- 
gastrium, or perhaps deep pelvic abscesses." 

Infiltration from rupture of the bladder is one of the 
rarest forms of this complication of stricture. Its 
method of production and effects, although more 
obscure, are almost precisely identical with infiltration 
from rupture of the urethra. If the bladder be tol- 
erably healthy, retention of urine will not produce 
rupture unless traumatism be superadded. For ex- 
ample, a fall or a blow upon the abdomen may produce 
it under such circumstances. Relief is usually afforded 
by rupture of that portion of the genito-urinary tract 
which offers the least resistance — i. e. the dilated and 
diseased portion of the urethra behind the stricture — or 
by overflow. A certain amount of urine may escape by 
distension of the diseased portion of the urethra, 
although the bladder cannot empty itself. In some 
cases overflow occurs as a consequence of subsidence of 
the inflammatory and spasmodic elements of the 
obstruction. By this time, however, the bladder has 
become so atonied by overdistension that the bladder 
cannot empty itself. When the bladder is ulcerated, as 
may be the case when a calculus complicates stricture, 
or when an instrument has been allowed to remain in 
contact with the vesical walls for a long period of time, 
the bladder walls may yield at the weakened point. In 
cases of extreme dilatation and sacculation of the 
bladder, the walls of the viscus are apt to yield to the 
pressure of the contained fluid at the point of least 
resistance, z. e. the thinnest and usually the largest 
sacculi. When rupture of the bladder occurs the con- 
tained fluid escapes into the cavity of the peritoneum. 

The symptoms of vesical rupture are in some 
respects the same as those of rupture of the urethra 
posterior to the triangular ligament. Upon examina- 



302 STRICTURE OF THE URETHRA. 

tion of the abdomen, however, the disappearance of 
the protuberance produced by the vesical tumor will 
indicate the character of the accident. In ordinary 
extravasation from rupture of the urethra the escape of 
fluid is not sufficient to cause the vesical tumor to per- 
ceptibly subside, although it may be enough to relieve 
the extreme tension of the vesical walls and to make 
the patient more comfortable. The shock resulting 
from rupture of the bladder is much more profound 
than that which occurs from rupture of the urethra, 
and almost inevitably proves fatal within a very short 
time. So much more likely is the urethra to rupture than 
the bladder, that in spite of the frequency of retention and 
the marked changes in the bladder wall which are apt to 
occur in old cases of stricture, rupture of that viscus is one 
of the rarest of complications. In the enormous expe- 
rience of Sir Henry Thompson he states he has never 
known of the existence of such an accident. The total 
number of cases reported will not exceed three or four. 

The treatment of infiltration must be prompt and 
energetic. As soon as symptoms indicating rupture of 
the urethra occur, perineal section and division of the 
stricture should be at once performed. Harrison's 
method of vesical drainage should be instituted by the 
insertion of a large rubber tube into the bladder. 
Thorough antisepsis by irrigations with very weak solu- 
tions of bichloride of mercury should be at once 
adopted. If diffuse swelling of the tissues of the peri- 
neum, scrotum, penis, thighs or groins exists, a free 
incision should be made at each prominent point. 

Whenever lancinating and throbbing pain, with 
more or less circumscribed swelling are perceptible in 
the perineum — whether the scrotum be involved or not 
— perineal section should be made. An examination 
per rectum will sometimes detect extravasated fluid in 
cases in which the symptoms are otherwise very obscure. 



OPERATION FOR INFILTRATION. 303 

Under such circumstances the perineal operation should 
be performed, and *a deep incision made in the direc- 
tion of the peri-rectal infiltration. In making this incis- 
ion the left index finger should be passed well up into 
the rectum to protect the gut from injury. 

The only hope for the patient in cases of extensive 
extravasation consists in active surgical interference by 
free incisions at all points where the infiltrated fluid 
can possibly be reached. Even if the extravasation 
and subsequent cellulitis and sloughing be very pro- 
nounced, a favorable result may often be secured by 
this radical measure. It is not sufficient to liberate the 
fluid that has already escaped, but it is necessary by 
section of the stricture and perineal drainage by the 
Harrison method to prevent further extravasation. 

Having obtained an outlet for the morbid urine, 
sloughs and inflammatory material incidental to extra- 
vasation, some antiseptic dressing should be applied 
which will not only tend to maintain the parts in an 
aseptic condition, but will conserve the vitality of the 
cellular tissues. The primary shock and secondary 
constitutional depression incidental to extravasation 
also constitute a most important indication in the man- 
agement of the case. Both indications may be fulfilled 
by the application of hot poultices composed of equal 
parts of charcoal and linseed meal, sprinkled liberally 
with brewer's yeast or a hot sublimate solution. All 
sloughs which may form should be detached as soon as 
they become loose, and the parts should be irrigated 
daily to remove discharge as fast as formed. As the 
sloughs separate, free purulent discharge occurs, con- 
stituting a severe drain upon the already depressed 
system. Liberal support, both dietetic and medicinal, 
will be required. Milk punch, egg-nog, large quantities 
of milk and concentrated broths should constitute the 
diet. A liberal quantity of stimulants, either brandy, 



304 STRICTURE OF THE URETHRA. 

whisky or the heavier wines, should be administered. 
Should the patient's stomach be irritable, champagne is 
required. Digitalis, carbonate of ammonia, quinine and 
tincture of the chloride of iron constitute the only 
reliable remedies against asthenia in these cases, and 
should be given in liberal doses. 

Rupture of the bladder incidental fo stricture 
demands the same treatment as under other circum- 
stances, but is inevitably fatal. 

Peri-urethral abscess is intimately associated with 
extravasation, but the latter may be of comparatively 
trifling importance per se, the collection of pus being 
relatively of much more serious moment. Abscess 
about the urethra may arise from several causes: 
(1) the escape of a drop or two of toxic urine into the cel- 
lular tissue as a consequence of solution of continuity of 
the urethral walls; (2) from the escape of a drop or two 
of urine into a dilated follicle with consequent free 
suppuration of the latter. The pseudo cyst finally rup- 
tures and produces abscess about the urethral walls. 
(3) Irritation and inflammation of the follicles due to 
the passage of instruments. (4) Puncture or rupture 
of the urethral walls at some point by the beak of an 
instrument. (5) Phlegmonous inflammation due to the 
absorption of organic poison from behind the stricture 
by the lymphatics; this poisonous material coming in 
contact with the cellular tissue, sets up suppurative 
inflammation. 

Peri-urethral abscess bears a distinct relation to 
peri-urethral phlegmon and folliculitis. When decom- 
posing urine escapes into the peri-urethral areolar 
tissue it sets up inflammation which induces a plastic 
exudate; in some instances the exudative material 
closes the orifice through which the urine escapes and 
prevents further extravasation, thus circumscribing the 
abscess. Abscesses of this kind may occur at any por- 



PLATE VII. 




Case showing the results of peri-urethral suppuration with resulting pocket and sinus 
formation in an old stricture involving nearly the entire extent of the urethra. 

{After Dittel.) 



PERI-URETHRAL ABSCESS. 305 

tion of the urethra, but are generally seen in the peri- 
neal part of the canal, on account of its frequent asso- 
ciation with stricture at the bulbo-membranous junc- 
tion. It may subsequently lead to extravasation, 
because of its opening into the urethra, thus per- 
mitting the escape of the urine into its cavity, the walls 
of which subsequently yield, or it may burrow to the 
surface externally and heal without difficulty. Again, 
it may open internally and burrow externally without 
extensive extravasation, the track of the pus being 
limited by plastic deposit. Under these circumstances 
fistula results. These abscesses are rarely dangerous 
per se, their importance being chiefly due to the danger 
of general extravasation and of the formation of uri- 
nary fistulse. 

Erichsen* states that "the extent and the amount 
of mischief done by urinary abscess will greatly depend 
on the side of the urethra on which it is situated. 
When, as usually happens, it forms at the lower surface 
of the canal it readily comes forward without much or 
extensive burrowing; but when situated on the upper 
wall of the urethra (which, however, is very rare) , or 
at the upper part of the side of the canal, it may bur- 
row widely before it points or is discharged externally, 
occasioning great induration, infiltration, and mischief 
in neighboring parts.' 

The symptoms of peri-urethral abscess consist of the 
appearance of a small, circumscribed, tender, painful 
and hard tumor somewhere in the course of the ure- 
thra. There is usually little or no constitutional reac- 
tion. Sometimes however, in extensive abscesses more 
or less fever is noticeable. When located in the peri- 
neum this part may become tense, hard and brawny, 
considerable weight and lancinating pain being com- 
plained of. Abscesses of this character are very slow 

*Op. cit., Vol. ii, p. 879. 



306 STRICTURE OF THE URETHRA. 

in coming to the surface because of the comparative 
density of Buck's fascia which binds them down. If the 
pus escapes from its environment of plastic exudate, it 
is most apt to follow the same course that is taken by 
infiltrated urine, there being less resistance to burrow- 
ing within the limits of Buck's fascia than to its escape 
externally. 

The treatment of peri-urethral and perineal abscess, 
consists of free incision with antiseptic precautions. 
It is bad practice to wait for fluctuation, unless the 
penile portion of the canal be affected, in which case 
nothing is warrantable but a small puncture to relieve 
the distention of the abscess and to prevent rupture 
into the urethra. Even in these cases however, if 
puncture demonstrates the presence of pus, the abscess 
cavity should be laid freely open. In perineal abscess 
a free incision should be made into the induration in 
the median line. Delay in these cases may lead to 
extravasation of urine. The after-treatment should 
consist in the ordinary surgical measures for the treat- 
ment of abscess in any situation. 

URETHRAL FISTULA. 

Urethral Fistulcz result from extravasation of urine 
and abscess. They are usually located in the per- 
ineum and scrotum, but have been noted in the 
groin, the inner aspect of the thigh, and upon the 
anterior abdominal wall as a consequence of extensive 
burrowing of pus. Their point of departure is gen- 
erally in the vicinity of the bulbo-membranous junc- 
tion; exceptionally they are met with in the scrotum 
and about the pendulous urethra. When they occur in 
the perineum they are often multiple, several openings 
being found about the perineum, nates, scrotum, and 
perhaps the inner aspect of the thighs. In a case re- 
ported by Civiale, over 50 external openings were 



URINARY FISTUL.E. 



307 



found in communication with the perineal portion of 
the urethra. There is something remarkable in the 
manner in which the pus will creep about and form 
secondary fistulae in these cases. 

The number, location, size, and length of fistulae 
are cardinal points in deciding their importance. Small 
perineal fistulce zvith a single or perhaps two openings are 
not of very great importance as they will close spontaneously 
in most cases as soon as all obstructions in the ttrethra have 
been removed. A very interesting case in illustration of 
this point recently came under my observation. 




W 

■ : if! 

"1 



Fig. 73- 

Extensive Fistulae from deep stricture of long standing. 

{After Bryant .) 

A young man had suffered from organic stricture 
of the deep urethra for six or seven years; this had 
been followed by perineal abscess and a fistula with 
two openings. Instruments had been introduced from 
time to time, so that the stricture had not closed suffi- 
ciently to produce retention. The fistulae would heal 
from time to time and perhaps remain closed for sev- 
eral months, when a collection of pus would form 
and they would again re-open. On examination the 
perineum was found to be hard and indurated, the tracks 
of the fistulae involving quite an area of the surrounding 
tissue. I found that the meatus was so small that it 



30 Z STRICTURE OF THE URETHRA. 

would admit only 12 French. This was surprising, 
inasmuch as the patient had been in the hands of 
several eminent surgeons from time to time, but it 
seems that they had contented themselves with merely 
passing small soft instruments. The fistulae had been 
open for several months when I first saw the patient. 
I incised the meatus, and they closed within three or 
four days and have never since re-opened. The stric- 
ture was found to be very hard, tortuous, indurated and 
resilient. Perineal section was proposed, but rejected 
by the patient, who was contented with palliation by 
the occasional introduction of a bougie, although at no 
time could an instrument larger than 22 French be in- 
troduced. Steel instruments could not be introduced 
at all. 

The size of fistulae depends entirely upon whether 
or not a loss of substance has occurred and upon the 
extent of the destruction. They may be large enough 
to admit several fingers. They are generally tortuous, 
narrow, and extend for a considerable distance. The 
external orifice may be very narrow and may heal from 
time to time as in the case just related. Under such 
circumstances the urine remains in the track of the fis- 
tula, decomposes, and again produces suppuration with 
external discharge. In some instances burrowing in 
other directions occurs with the result of producing 
tributary fistulse running in various directions. The 
tissues of the scrotum, penis and perineum in cases of 
multiple fistulae, become extremely hard and thickened, 
having a feel to the fingers almost like cartilage. 
Where the stricture is very tight and the fistula com- 
paratively large the urine may not pass through the 
normal channel at all, entirely escaping via the fistula. 
Rarely indeed, does the stricture become completely 
agglutinated, although such an accident may possibly 
occur in cases of traumatic stricture. 



TREATMENT OF FISTULA. 309 

The treatment of fistulce depends upon their loca- 
tion, number, and the question of the loss of substance. 
The first principle in their management consists in the 
removal of all obstructions to the outflow of urine. A 
dilated meatus and strictures in the penile portion of 
the canal require incision as under ordinary circum- 
stances. Care should be taken to completely restore 
the calibre of the urethra, for the more perfectly this is 
done the less resistance there is to the outflow of urine. 
By this procedure we take advantage of the physical 
principle that fluid tends to flow in the direction of the 
least resistance. Should there be at any point in the 
course of the canal, sufficient obstruction to produce dis- 
tension of the urethra behind it, the backward and out- 
ward pressure will necessarily force a portion of the 
urine into the internal orifice of the fistula and thus 
prevent healing. The majority of simple perineal fistulcE 
will be found to close spontaneously as' soon as the normal 
calibre of the urethra has been restored. The tissues in 
this situation are thick, and reparative action is conse- 
quently much more active than is the case in the pen- 
ile portion of the canal. Then too, the parts are not 
disturbed \>y erections, which, by depriving the affected 
tissues of rest necessarily interfere with granulation 
and retard the process of healing. 

Should simple fistulae show a disposition to become 
chronic in any portion of the canal, the patient should 
be instructed in the use of the catheter and directed to 
draw his urine at regular intervals, thus obviating the 
possibility of the passage of the fluid through the fistula. 
Should such measures however, tend to set up irritation 
of the urethra and bladder, it will be necessary to discon- 
tinue them. 

The process of repair may often be stimulated by 
cauterization of the track of the fistula. A good plan is 
to enlarge the external orifice of the fistula and pare its 



3IO STRICTURE OF THE URETHRA. 

edges, its track may then be cauterized by passing a fine 
platinum wire attached to a galvano-cautery apparatus. 
This is passed into the fistula when cool and then heated 
to a white heat and rapidly withdrawn. A fine probe, 
coated with a bead of sulphate of copper or nitrate of 
silver, may be used for the purpose of cauterization 
instead of the galvano-cautery. After the operation a 
soft, moderate sized catheter should be left in the blad- 
der to prevent any escape of the urine through the fis- 
tula. A catheter should be allowed to remain in the 
bladder for a couple of days. The viscus should be 
irrigated with a warm mild antiseptic solution, at least 
once daily. Applications of the tincture of iodine upon 
a cotton wrapped probe are sometimes effectual in 
promoting healing. 

If the stricture be hard, resilient, or irritable, the 
best plan is to perform perineal section. All branching 
fistulae which can be gotten at had best be laid open and 
left to granulate from the bottom at the same operation. 
After a perineal section in stricture complicated by fis- 
tulae the Harrison method of drainage should be 
adopted. This not only drains the bladder, but pre- 
vents the urine — which is invariably of an irritating 
character, — from coming in contact with the fistulae. 
Fistulae located in the scrotum often require free incision 
after the removal of urethral obstructions. Such fistulae 
will often be found to be connected with unhealthy, 
sloughy abscess cavities. These should be laid freely 
open and made to granulate from the bottom. 

Siphon drainage has been recommended for sim- 
ple fistulae in the perineum. This method consists of 
tying a moderate sized soft catheter in the bladder. 
This is attached to a rubber tube of considerable length, 
which passes into a receptacle containing carbolized 
water. Four cases are reported by Chiene* which were 
cured in this manner. 

♦Transactions of the Edinburgh Medico-Chirurgical Societ , 1880. 



TREATMENT OF FISTUL.E 3II 

The importance of rest in treatment of urinary 
fistulae cannot be overrated. I remember a case of per- 
ineal fistulae which entered the New York Charity Hos- 
pital some years ago, that had lasted for some little 
time after the calibre of the urethra had been restored, 
and which healed spontaneously after four weeks' rest 
in bed. 

Urinary fistulae occasionally open into the rectum, in 
which event we have superadded to the obstacle to heal- 
ing afforded by the contact of the urine, an additional 
element, viz.: the escape of fecal matter and gases. 
These latter materials are likely to pass not only into 
the fistula, but entirely through it into the urethra. Fis- 
tulse of this sort are not apt to heal even after the ure- 
thra has been restored to its normal calibre. The ordi- 
nary operation for rectal fistula should be performed in 
such cases, the rectum and the greater portion of the 
track of the urinary fistula being laid into one cavity 
and made to granulate from the bottom. The rectal 
extremity of the fistula having healed, there may still 
be an opening in the perineum, the urine alone being 
sufficient to keep the urethral extremity of the fistula 
from healing. The perineal fistula may now be treated 
as under ordinary circumstances. 

Thompson 1 records an instance of successful treat- 
ment of recto-urethral fistula by position, the patient 
being instructed to pass urine only in the prone posi- 
tion. 

Large fistulae due to a greater or less destruction 
of the tissues by which they are surrounded require, as 
a rule, special measures of operative treatment. The 
same may be said of fistulae which fail to heal under the 
measures of treatment already outlined. Fistulae in the 
penile portion of the canal, whether there be any loss 
of substance or not, are apt to be intractable to treat- 

* Diseases of Ur.nary Organs, p. i46. 



312 STRICTURE OF THE URETHRA. 

ment. This intractability is due to the extreme tenuity 
of the tissues, which is unfavorable to plastic exudate 
and repair, and to the variable position of the organ 
incidental to erection and the performance of the sex- 
ual function, which prevents the necessary rest. Even 
with considerable loss of substance in the perineum, 
fistulae in this region will often close spontaneously, 
granulation and repair being very active and the parts 
being relatively infrequently disturbed. Loss of sub- 
stance may occur in cases of fistulae due to gangrene 
and sloughing, extensive abscess, phagedena, or the 
prolonged contact of instruments with the canal. Neces- 
sarily they are most often noted in severe cases of 
stricture. 

Urethroplasty is usually necessary in large fistulae of 
the penile urethra. 

Astley Cooper,* however, reported a case in which 
the application of nitric acid was successful in closing a 
fistula as large as a good sized pea after two successive 
plastic operations had failed. 

Dieffenbach has suggested the application of a 
strong tincture of cantharides, which destroys the epi- 
thelium and stimulates the formation of granulations. 

Perineal Jistulce may often be closed by a compara- 
tively simple operation. The edges should be liberally 
pared and brought together with the quilled or shotted 
suture. I have succeeded in curing several of them 
by repeated suturing after preliminary cauterization. 

Scrotal Jistulce require free paring of their edges. 
The tissues about the fistula should be extensively dis- 
sected up to secure thick, good sized flaps of skin and 
areolar tissue. These should be stitched together by 
silver wire or by the quilled or shotted suture. Several 
operations may be necessary before the cure is com- 
plete, each operation making the fistula smaller. The 

*Surgical Essays, London, i8i9,p. 2o5. 



TREATMENT OF FISTULA. 313 

urine must be drawn in all instances by the catheter. 
If the urethra be tolerant of the instrument a moderate 
soft sized catheter may be left in the bladder for sev- 
eral days. Irrigation of the bladder is necessary to 
maintain it as far as possible in an aseptic condition, so 
that in case urine comes in contact with the wound it 
may not prevent healing. 

As a substitute for plastic operations Dieffenbach 
proposed a much simpler operation. A concentrated 
tincture of cantharides is applied to the edges of the 
opening and tract of the fistula. As soon as the epi- 
thelium has become detached and the surfaces are suffi- 
ciently raw a good sized soft bougie is introduced into 
the canal; a needle armed with a strong, well waxed 
silk thread is now introduced about a quarter of an inch 
from the edge of the fistulous opening. This is passed 
into the tissue of the corpus spongiosum for a short dis- 
tance, and then made to emerge. It is re-introduced at 
the point of emergence, passed along and brought out 
again in the same manner and at the same distance 
from the edge of the fistula. This is repeated until the 
ligature completely encircles the fistula and terminates 
at the first point of introduction. The thread bears the 
same relation to the fistula that a draw string does to 
the mouth of a bag. The two ends of the ligature 
being drawn together, the freshened surfaces of the 
fistula are closely approximated. A knot is now tied 
and allowed to sink into the point of puncture. The 
urine is to be drawn at regular intervals by means of a 
catheter. The ligature is allowed to remain for three 
or four days, then cut and withdrawn. Several opera- 
tions may be necessary before the fistula is completely 
obliterated. The operation is only applicable to fistulae 
of small size. 

In the penile portion of the canal it is quite difficult 
to perform a successful operation of urethroplasty. 



314 STRICTURE OF THE URETHRA. 

This is due to the thinness and looseness of the integu- 
ment, and to the sparsity of cellular tissue in this part. 
So scanty are the tissues that the surgeon naturally 
hesitates to pare the surfaces of the fistula sufficiently 
to obtain the desired result. Obviously, flaps with thick 
edges, such as can be secured in the perineum, heal 
much more readily than the thin ones which it is prac- 
ticable to secure in the penile portion of the canal. 
Erections frequently occur and constitute another 
obstacle to success, as they produce tension and abso- 
lutely prevent the necssary rest. 

Several special operations of urethroplasty have 
been devised. One of the best of these is that of 
Szymanowski.* This operation is performed in the 
following manner: When the fistula lies in the long 
axis of the penis a straight incision is to be first made, 
beginning just in front of the fistula and terminating a 
short distance behind it. The integument upon one 
side is then to be dissected up so as to be freely mov- 
able. A half oval flap of skin on the other side of the 
fistula is then outlined and dissected up, excepting at 
the edge of the fistula, its epidermis being first removed. 
The dissected flap is then to be inverted and pushed 
under the skin which has been freed upon the opposite 
side, as into a pocket. It is then to be retained in 
position by sutures passed into and through the bottom 
of the pocket. The movable skin is then slid over it 
and also stitched. An elastic catheter is to be passed 
into the bladder and there retained. This operation 
has been practiced and highly recommended, especially 
by such excellent operators as Drs. Charles McBurney, 
Robert F. Weir,f E. L. Keyes and T. T. Sabine. I 
have employed the method in two cases with most 

gratifying success. 

*Hand-book of Operative Surgery, i87o. 
fMedieal Record, April 13, i878. 



URETHROPLASTY. 315 

Dr. McBurney* has practiced a modification of the 
operation in a number of cases with great success. In 
a report of six cases this gentleman speaks as follows: 

"One case, the first, owing to imperfect manage- 
ment, failed completely. Five cases succeeded, and in 
none of them was any second operation required. 

The second case required three months and six 
days to obtain sound healing; the third, seventeen days; 
the fourth, thirteen days; the fifth, nineteen days; and 
the sixth, thirty-four days. No symptom of the slight- 
est importance occurred in any of the last five cases, 
and the length of time occupied in recovery certainly 
compares very favorably with that often spent in futile 
and even successful attempts to close perineal fistula 
without operation. 

The plan adopted in all of these cases was as fol- 
lows; and, if the description seems tedious, my excuse 
must be that I believe the success Df the operation to 
depend largely upon a close attention to details: 

Some time previous to operation the entire urethra 
was cleared of all evidence of stricture, and the urethra 
accustomed to the passage of sounds; any sinuses in 
the neighborhood of the fistula were opened and 
soundly healed. If cystitis existed, it was removed as 
far as possible, although a moderate amount of chronic 
cystitis certainly does not contra-indicate the operation. 

The day before operation the bowels and rectum 
were thoroughly cleared in order, especially, that for 
several days afterward the rectum and adjacent parts 
might be kept perfectly quiet by a free use of opium. 
The perinaeum was then shaved and carefully cleansed, 
and the bladder emptied with the catheter and thor- 
oughly washed out with a weak solution of either 
borax or carbolic acid. The edges of the fistula were 
then either scraped or cut so as to remove all suppu- 

* New York Med. Jour., November 6, 1886. 



3i6 



STRICTURE OF THE URETHRA. 



0; 




V 




rating granulations which would naturally increase 
discharge and prevent early union. 

A single straight incision was then made, from A, 
three quarters of an inch in front of, to B, three quar- 
ters of an inch behind, the fistula (Fig. 74) . This incis- 

ion passed 
through skin 
and superficial 
fascia, and 
closely skirted 
, the right side of 
the fistula. The 
edge of this in- 
cision was raised 
and, working 
with a small 
blade to the 
patient's right 
side, the skin 
and fascia were 
undermined un- 
til a pocket was 
formed includ- 
ing the area A 
C B F, the right 
edge of the poc- 
ket being in- 
B dicated by the 

dotted line A C 

Fig. 77- g 

On the opposite side, a curved incision A D B was 
then made, the greatest width of the flap thus marked 
out being three quarters of an inch to one inch. 

This flap must be generous and should include a 
good padding of fascia as, when it is lifted, the shrink- 
age is great. 




\ 



URETHROPLASTY. 317 

Before lifting the flap a thin layer of skin was 
removed from its surface. This is best done with 
small curved scissors, the superficial layer of skin being 
rapidly chipped off. 

The freshening process was carefully extended 
over the entire area A D B F, excepting over a surface 
a little larger than the fistula, and immediately next 
to it. 

It was thought best to leave this portion undenuded 
for the immediate cover to the fistula, because less 
cicatricial repair would occur, and less pus would be 
formed than if a raw surface were presented to the 
urethra (see Fig. 75.) The flap A D B was then dis- 
sected up close to the median line and inverted, its 
attached edge acting as a hinge and as a medium for 
blood supply. 

Five or six fine catgut sutures were passed through 
the skin at different points a little beyond the dotted 
line, A C B, into the pocket, then through the free edge 
of the flap, and then back into the pocket and out 
through the skin. Five or six loops were thus formed, 
by drawing upon which the flap was closely drawn down 
to the bottom of the pocket, and the free ends of the 
loops were tied.* (See Fig. 76.) Two or three sutures 
of catgut were now passed with a curved needle through 
the upper surface of the inverted flap so as to firmly 
bind it to the parts beneath. Sometimes with inter- 
rupted and sometimes with a continuous catgut suture 
the free edge, A F B, was now securely fastened to the 
edge, A D B.f (See Fig. yy.) Irrigation with carbolic 
acid or bichloride solution was used throughout, except- 
ing in the first case. 

The dressing consisted of iodoform, iodoform 
gauze, and a cotton pad, held in place with aT-bandage. 

*In the first two cases silk was used, and, I think, interfered with healing.— (McBurney.) 
fThe line of suture was thus removed to a distance from the fistula, large raw sur- 
faces were brought in contact, and two thick layers covered the fistula.— (McBurney.) 



318 STRICTURE OF THE URETHRA. 

A morphine suppository was usually introduced before 
the dressing. 

The subsequent treatment consisted in a free use 
of opium to prevent the rectum from acting, and the 
use of the soft catheter, the latter at least every six 
hours and as much oftener as was required. Some- 
times the catheter would be required as frequently as 
every three hours, and sometimes it caused moderate 
urethritis. 

The catheter was always, excepting in the first 
case, thus used: It was introduced and the water 
drawn off. The bladder was then gently washed out 
with a weak solution of either carbolic acid or borax; I 
prefer the latter. On withdrawing the instrument the 
end was tightly pinched until the whole catheter had 
been removed from the urethra. This plan seemed to 
reduce the chance of contaminating the wound with 
urine from the inside to a minimum, and is certainly 
much to be preferred to the practice recommended by 
Szymanowski of tying in a catheter, or that made use 
of by me in my first case of puncturing the bladder 
through the rectum." 

Nelaton's Operation has been somewhat popular. 
It is performed in the following manner. The edges of 
the fistula should first be freely pared; the surrounding 
skin for an area of about an inch in breadth and extend- 
ing a little beyond the fistula anteriorly or posteriorly 
should then be dissected subcutaneously by a narrow 
bladed knife introduced posterior to the fistula. The 
raw edges of the latter are then brought together by 
fine sutures. 

Another method is proposed by the same surgeon. 
The edges of the fistula are first pared and the skin 
separated for about half an inch upon each side of the 
opening. Lateral incisions are then to be made at a 
distance of about half an inch from the pared edges of 



URETHROPLASTY. 



3*9 




the fistula, for the purpose of relieving tension. A slip 
of thin India rubber tissue may then be passed under- 
neath the flaps of skin in order to prevent contact of 
urine with the raw edges and con- 
sequent disturbance of adhesion. 
Should the fistulous opening close, 
the lateral incisions very promptly 
heal. In both of these operations 
the extensive separation of the skin 
causes abundant granulations to 
spring up with the result of closing 
the fistula. 

In cases of extensive fistulae of 
the penile urethra perineal drainage 
may be established after a plastic 
operation has been performed. 

Ricord recommended for cases 
in which perineal or scrotal fistulae 
co-exist with fistulae in the pendulous 
urethra that a catheter be passed 

through the lower fistula for the 
purpose of draining the bladder 
during the treatment of the penile 
lesion. He also suggested punctur- 
ing the bladder. Erichsen recom- 
mends that this be done through 
the rectum, but the Harrison 
method of perineal drainage is 
far better. The opening made in 
the perineum by this latter opera- 
tion will almost invariably close 
spontaneously when it has sub- 
served its function. 

An operation for extensive pen- 
ile fistula was recommended by Le Gros Clark. This 
is performed as follows: The edges of the fistula hav- 



Fig. 78. 

Nelaton's Operation for 

Penile Fistula. 




Fig. 79- 

Nelaton's Operation for Penile 

Fistula. 



320 



STRICTURE OF THE URETHRA. 



ing been thoroughly pared, a transverse cut about an 
inch in length is made through the integumentary 
coverings of the penis a little distance in front of 
the fistula. (a) Two transverse incisions are then 
made at the peno-scrotal angle, each being about an 
inch and a half in length. These transverse incisions 
are connected at each end of the fistula by a short 
longitudinal incision. (6) The flaps of skin thus out- 
lined are dissected up and brought together by means 
of clamps or the quilled suture. By this procedure 





Fig. 80. 
Clark's Operation for Penile 
Fistula — First Step. 



Fig. 81. 

Clark's Operation for Penile 

Fistula — Second Step. 



two broad raw surfaces (at c) are brought together 
instead of a narrow raw edge of skin, and there is 
therefore a much better prospect of successful union. 

Stone in the Bladder complicating stricture is occa- 
sionally seen. The calculus under such circumstances 
may be of renal or vesical formation. In the first 
instance a small uric acid or oxalate of lime calculus 
comes down from the kidney and lodges in the bladder, 
and forms in the ordinary manner a nucleus for a 
calculus of variable size. In the second instance, as a 
consequence of secondary vesical disease with co-inci- 
dent decomposition of urine, a phosphatic calculus forms 



PROSTATIC HYPERTROPHY. 32 I 

in the bas fond. In cases in which calculus co-existswith 
a slight stricture that is susceptible of treatment by 
dilatation or urethrotomy,the stricture should be treated 
in the ordinary manner, measures being at the same 
time carried out which will tend to keep the bladder in 
as healthy a condition as possible, until such time as it 
is practicable to operate upon the stone by litholopaxy, or 
if the stone be too large for this operation, by lithotomy. 
In cases of hard and indurated stricture of the deep 
urethra with vesical calculus as a complication, perineal 
section may be performed and the calculus removed as 
in the ordinary median operation for stone, or the 
median operation and lithotrity may be combined, if 
the stone be too large to be extracted with a forceps. 
It is advisable to avoid the lateral operation if it is pos- 
sible to do so. In cases of very large stone complicating 
organic stricture — the latter requiring perineal section — 
it is my opinion that supra-pubic lithotomy is the most 
rational mode of operation. 

PROSTATIC HYPERTROPHY. 

Enlarged Prostate as a complication of stricture 
is very exceptionally seen, for the reason that stricture 
has usually manifested itself and has demanded and 
received attention prior to the period of life at which 
enlargement of the prostate is likely to first cause 
annoyance. Even when stricture and enlarged pros- 
tate co-exist the latter is not apt to prove a serious 
complication, unless the tumor which it forms is very 
large and interferes with the passage of instruments 
beyond the bulbo-membranous junction. Stricture in 
the penile portion of the canal should he treated upon 
the same principles as though enlarged prostate did 
not exist. In cases of deep and tight stricture, con- 
tinuous dilatation should be practiced until an instru- 
ment of moderate size can be passed. Steel instru- 



322 STRICTURE OF THE URETHRA. 

ments of the proper prostatic curve should now be used 
for dilatation. If the stricture be very tight and hard, 
and retention exists, external perineal urethrotomy 
should be performed. There is one compensating 
advantage in the necessity of this operation which is, 
that in case circumscribed portions of the enlarged 
prostate should be found to constitute the principal 
obstruction at the mouth of the bladder, they may be 
removed at the same operation. 

I have recently had a trying experience with a case 
of retention in a man of 60, who also had a stricture of 
the deep urethra. Fortunately the stricture was not 
very tight and yielded in a few days, retention being 
meanwhile relieved by the aspirator. As soon as 
instruments could be passed, continuous dilatation was 
practised for a few days. Gradual dilatation by soft 
flexible bougies was then substituted and the urethra 
moderately dilated. The case was lost sight of before 
it could be conducted to a cure, as far as the stricture 
was concerned, but when last heard from the patient 
was in a very comfortable condition, and considered it 
unnecessary to submit to further treatment. 

Inflammation of the Seminal Vesicles: It has 
recently been shown by Mr. Jordan Lloyd and others, 
that the seminal vesicles are not infrequently involved 
in gonorrheal inflammation. Those who have studied 
the subject are particularly impressed with the analogy 
of pathological processes occurring in the seminal vesi- 
cles and those of the Fallopian tubes. There seems to 
be no question that in old cases of stricture and chronic 
urethritis, the seminal vesicles may be the seat of 
chronic pathological changes. Mr. Lloyd's conclusions 
are as follows: 

1. It is not a rare affection. 

2. It is analogous to diseases of the Fallopian 
tubes. 



CYSTITIS FROM STRICTURE. 323 

3. It is usually secondary to urethritis. 

4. The vesiculse seminales become distended by 
obstruction. 

5. Suppuration is unusual, but may occur. 

6. Such abscesses should be opened from the peri- 
neum, never from the rectum. 

7. Gonorrhoea is by far the most common origin. 

8. It is often diagnosed as prostatitis. 

9. It is often concomitant with gonorrhceal epi- 
didymitis. 

10. The diagnosis is best made by rectal explora- 
tion. 

Cystitis. — Inflammation of the bladder is a frequent 
complication of stricture of the urethra. It varies in 
severity from the so-called inflammation of the vesical 
neck, to the severe and intractable form of chronic inflam- 
mation met with in some severe and long-standing 
strictures. 

A lengthy discussion of cystitis and its treatment 
would be out of place in a work of this kind, but a few 
practical points are essential to completeness. 

Inflammation of the vesical neck — more properly 
described as posterior urethritis — is a very frequent re- 
sult of stricture. It may be acute or chronic, and results 
in one of two ways — or in a combination of the two — 
viz.: extension of the primary gonorrhceal inflammation 
to the prostatic sinus, where it becomes chronic, or by 
gradual infection of the deep urethra from the infec- 
tious process behind the stricture. Oftentimes a dirty 
instrument is responsible for infection of the deep ure- 
thra. The relation of the instrument is occasionally 
only that of a carrier of poison from the anterior ure- 
thra — or from that portion of the canal which is affected 
by the stricture — into the deeper parts. In some instances 
the instrument lights up traumatic inflammation of the 



324 STRICTURE OF THE URETHRA. 

strictured portion of the canal, which extends by con- 
tiguity to the vesical neck. 

One of the most important elements in the produc- 
tion of posterior urethritis, is the reflex irritation, con- 
gestion and spasm of the muscular urethra and vesical 
neck, induced by the stricture. This will result in 
stricture of large calibre in the penile portion as readily as 
in stricture of the deeper portion. The indication in any 
case of cystitis complicating stricture, is to remove the 
cause. It is well to remember however, that acute 
cystitis occurring in the course of stricture must be 
handled with some circumspection. It is generally well 
to allow the acute inflammation to subside somewhat, 
before tampering with the stricture. Oftentimes cys- 
titis persists after removal of the stricture which caused 
it, and it may require prolonged and careful treatment 
for its subjugation. 

Cystitis of the vesical neck — i. e., posterior ureth- 
ritis — may often be nipped in the bud by an injection 
of a five or ten grain solution of the nitrate of silver 
via the Ultzmann deep urethral syringe. 

It is probable that certain changes occurring in the 
bladder as a result of the sudden relief of prolonged 
retention, have much to do with the occurrence of 
cystitis in stricture. Heubnerhas performed some very 
interesting experiments tending to show the important 
relation of sudden circulatory fluctuations to cystitis. 
One of his most striking experiments consisted of the 
ligation of the vesical artery for two hours. The tem- 
porary ligature being removed at the end of this time, 
it was found that coincidentally with the restoration of 
the circulation there occurred extensive exudation and 
coagulation necrosis of the vesical walls. This experi- 
menter also found that if septic bacteria were intro- 
duced at the same time the circulation was restored, 
they accumulated in great numbers at the site of the 



EPIDIDYMITIS FROM STRICTURE. 325 

pathological changes mentioned. Cornil produced sep- 
tic nephritis by ligating the renal artery for some hours, 
then removing the ligature and injecting pyogenic 
organisms into the blood. It would seem then that the 
local innutrition produced by temporary anaemia of the 
bladder and kidney structure predisposes to the mor- 
bific action of pathogenic bacteria under the local dis- 
turbance produced by sudden restoration of the circula- 
tion. The facts above cited have a much more impor- 
tant bearing upon cystitis following prolonged retention 
from enlarged prostate, but it is at least fair to assume 
that they are pertinent to certain cases of cystitis in 
stricture. 

Pyelitis in stricture is in nowise different from 
that which occurs in other inflammatory and obstruc- 
tive conditions of the genito-urinary tract. A full pres- 
entation of the subject is hardly in keeping with the 
scope of this work. Pyelitis from" stricture varies in 
degree from a slight catarrhal inflammation, to severe 
and intractable inflammation with a profuse formation 
of pus. The disease is so constant an ingraft upon 
stricture, that a greater or less degree of pyelitis is to 
be inferred in all long-standing and severe strictures. 
Pyelitis may persist and steadily grow worse in spite of 
the removal of the original cause. In some cases a 
severe degree of pyelitis is present — judging from the 
amount of pus present in the urine — yet the patient 
appears to tolerate the difficulty without much dis- 
turbance resulting. One of the chief dangers of stric 
ture is a sudden exacerbation of pyelitis, the resulting 
inflammation — pyelonephritis — involving the kidney 
structure proper. 

Epididymitis is often met with in stricture, and 
occurs repeatedly in some patients throughout the 
course of treatment. It may result from infection by 
materials formed behind the stricture — the products of 



326 STRICTURE OF THE URETHRA. 

bacterial evolution — or it may be due to a sudden 
exacerbation of inflammation in and about the stricture 
brought on by instrumentation, dietary indiscretions, 
sexual excitement or over exertion. Epididymitis in 
stricture may be acute, subacute or chronic. Often- 
times the process is subacute and results in the forma- 
tion of a small, hard, tender nodule in the globus major. 
In tubercular patients, very serious results may 
ensue. The principal point to be borne in mind is that 
stricture of the urethra is a constant invitation to inflam- 
mation of the epididymis, which maybe avoided by the 
use of a properly fitting suspensorv, and avoidance of 
all sources of sexual excitement, over-exertion and in- 
dulgence in liquors or high living. Care in instrumental 
manipulations is a still more important prophylactic 
measure. The importance of avoiding epididymitis, as 
a menace to fertility, is at once manifest, but in my 
opinion receives too little consideration at the hands of 
the surgeon. Impotentia generandi is not an extra- 
ordinarily rare result of stricture, and a very small nod- 
ule in each epididymis may be all sufficient to pro- 
duce it. 

Impotence. True or false impotence may result 
from stricture. One of the most frequent effects of 
stricture is a reflex inhibition of the erectile power — per- 
haps dependent on disturbance of the nerves of sexual 
sensibility in the prostatic sinus. It is obvious that the 
disturbance maybe due to a direct impression upon the 
deep urethra. In many instances the impotence associ- 
ated with stricture is altogether due to mental disturb- 
ance incidental to the knowledge of the presence of the 
stricture. Impotentia coeundi may be due to a chronic 
chordee produced by the stricture. In such cases the 
neoplastic formation produces pressure obstruction of 
the blood vessels and also by its inelasticity causes an 
incurvation of the penis at the affected point. 



IMPOTENCE FROM STRICTURE. 2> 2 7 

Impotentia generandi may exist, copulation being" 
satisfactorily performed, but true sterility existing. 
This is due to mechanical obstruction to the passage of 
the semen. 

Impotence and sterility usually disappear on 
removal of the stricture. In some cases, however, 
impotentia coeundi of mental origin will remain after 
cure of the stricture, and will require careful manage- 
ment. 

Imperfect erection is a not infrequent sequel ot 
stricture under any method of treatment, and may be a 
permanent source of disquiet. This most often occurs 
after urethrotomy. 



INDEX. 



PAGE. 

Anatomy of the Urethra 3 

Antisepsis and Asepsis in Urethral Surgery 31 

Annular Stricture 78 

Antiseptics, Internal Administration of in Stricture 136 

Antispasmodics, use of, in Stricture 137 

Arnaud and Butte, Neuopathic Albuminuria 187 

Antogenesis, Relation of to Urinary Toxaemia 190 

Alter treatment in Urethrotomy 227 

Aspirator, use of, in Retention of Urine 281 

Abscess, Peri-urethral, as a Complication of Stricture 304 

Buck's Fascia 18 

Buck's Fascia, Illustration of. 19 

Buck's Fascia, Cavity Formed by , 20 

Benique, Sound of 30, 169 

Bladder, PathologicaliChanges in, from Stricture 106 

Bladder, Rupture of, from Retention 301 

Bougie a Boule, Diagnostic Value of. 1 21 

Banks (E- A.), Whalebone Bougie * 167 

Brodie (Sir Wm.), Catgut Bougies 167 

Bougies, Whalebone 167 

Bougies, Olivary 168 

Brown (W. T.), Urethral Speculum 177 

Bryant, Case of Multiple Urinary Fistula 307 

Caput Gallinaginis 1 3 

Cowper, Glands of. 16 

Care of Urethral Instruments 33 

Congestive Stricture 50, 70 

Cruveilhier, cut off Muscle of. 21 

Chronic Spasmodic Stricture 58 

Conformation of Instruments 29 

Congenital Stricture 74 

Causes of Organic Stricture 110 

Chancre and Chancroid, Causation of Stricture by Ill 

Caustics, use of in Stricture 138 

Continuous Dilatation 170 

Chronic Uraemia in genito-urinary Disease 204 

Civiale, Urethrotome of. 219 

Civiale, Case of Extensive Multiple Urinary Fistula 306 

CurvatuTe of Penis Following Urethrotomy 225 

Complications of Stricture 276 

Cock's Operation of Perineal Cystotomy 285 

Chiene, Siphon Drainage for the Cure of Urinary Fistula 310 

Cooper (Sir Astley), Nitric Acid in Urinary Fistula 312 

Cantharides, use of in Urinary Fistula 312 

Clark (Le Gros), Operation for Extensive Penile Fistula 319 

Cut Off Muscle 21 

Cut Off Muscle. Spasm of. 22 

Curve of Urethra 29 

Cystitis, Complicatory Stricture 323 

329 



33° INDEX. 

Deep Fascia of Perineum 22 

Definition of Stricture 48 

Degrees of Contraction in Stricture 82 

Desnos (M.), Relation of Slight Traumatism to Stricture 93 

Density of Stricture 109 

Diagnosis of Stricture 119 

Deep Urethra, Stricture of. , 152 

Dilatation, Untoward Effects of ... 180 

Divulsion, Operation of. 213 

Divulsion, Indications for use of. 216 

Dieffenbach, use of Cantharides in Urinary Fistula 312 

Erectile Tissue of Penis 17 

Elasticity of the Urethra 94 

Elasticity of the Urethra, Impairment of 94 

Exploration of Urethra by Bulbs 126 

Eucalyptus, use of in Stricture 136 

Endoscopy, Instruments for 177 

Endoscopy, Technique of 177 

Edes (R. W.), Nervous Lesions as a Cause of Albuminuria 

Engleman (Geo. J.), Renal Disturbance from Reflex Action 189 

Erichsen (J. E.), Urethral Chill in Female 202 

Erichsen (J. E.), Case of Perineal Section 250 

Eldridge (Stuart), Case Showing Permanent Results of Urethrotomy 238 

External Urethrotomy 245 

Electrolysis of Stricture. 261 

Fossa Navicularis 10 

Fossa Navicularis, Section of. 11 

Fascia of Perineum 18 

Form of Metallic Instruments 37 

Female, Urethral Stricture in 73 

Friction, Relation of to Stricture 97 

Finger (E.), Injection of Deep Urethra 178 

False Passages from Dilatation ..., 207 

False Passages, Symptoms of. 208 

False Passages as a Complication of Stricture 276 

Fort (J. A.), Linear Electrolysis 270 

Forcible Instrumentation 276 

Forcible Catherization in Retention 284 

Fistula from Stricture 306 

Fistula, Treatment of. 309 

Glands of the Urethra 14 

Gleet, Association of with Penile Stricture 142 

Gleet, Various Causes of 148 

Gouley (J. W. S.), Whalebone Guides , 166 

Gouley (J. W. S.), Rapid Dilator 215 

Gouley (J. W. S.), Dilating Urethrotome 218 

Gradual Dilatation 172 

Granular Urethritis 179 

Guyon (F.), Bougie a Boule 122 

Heredity, in the Etiology of Stricture , 212 

Harrison (R.), Remarks on Urine Fever 181 

Harrison (R.J, Combined Method of Urethrotomy 248 

Holbrook, Nerve Terminations in the Kidneys 188 

Haemorrhage from Dilatation 206 

Holt, Divulsor for Stricture 

Hypertrophy of the Prostate as a Complication of Stricture 321 

Instrumentation of the Urethra : 30 

Instrumentation of the Urethra, Method of 39 



INDEX. 



331 



Instruments, Care of. 30 

Instruments, Lubrication of. 34 

Inflammatory Stricture 50 70 

Inflammatory Stricture, Causes of. 7 q 

Inflammatory Stricture, Treatment of. 7! 

Irregular Stricture, Illustration of. 73 

Injections, Causation of Stricture by W2, 

Inflammation of the Bladder from Dilatation 211 

Inflammation of the Testicles from Dilatation 211 

Inflammation of the Prostate from Dilatation 210 

Internal Urethrotomy 217 

Infiltration of Urine 286 

Infiltration of Urine, Direction Taken by 287 299 

Infiltration of Urine, Effects of. 290 

Infiltration of Urine, Treatment of 302 

Impotence from Stricture 325 

Klotz (H. G.), Endoscope 177 

Kej^es (E. L.), Discussion and Experiments on Urinary Extravasation 291 

Keyes (E. L.), Direction of Urinary Extravasation 299 

Littre, Glands of 14 

Lacuna Magna 15 

Lubricants for Instruments 34 

Linear Stricture 76 

Location of Stricture 89 

Long (J. W.), Remarks on Reflex Renal Disturbance 186 

Linear Electrolysis 270 

Meatus Urinarius 6 

Membranous [Urethra * 11 

Membranous] Urethra, Structure of 12 

Morgagni, Sinuses of. 14 

Morbid Anatomy of Stricture 102 

Morris (H.), Case Showing Extreme Results of Stricture 107 

Meatatome of Civiaie 123 

Meatatome of Piffard 123 

Meatotomy 123 

Meatotomy, Dilatation After 125 

Morphia, use of in Stricture 137 

Methods of Treatment, Selection of. 137 

Meatal Stricture, Treatment of. 139 

Meatoscope 177 

Medication of Deep Urethra 178 

Maisonneuve, Urethrotome of. 218 

Mastin (C. H.), Subcutaneous Division of Stricture 254 

McBurney (Chas. F.), Urethroplasty 315 

Neurosis in Stricture 116 

Nervous Manifestations from Urethral Operations 200 

Newman (R.), Electrolysis of Stricture 263 

Nitric Acid, Use of in Urinary Fistula 312 

Nelaton, Operation for Urinary Fistula 318 

Nelaton, Operation for Urinary Fistula, illustration of. 319 

Operation of Sounding ^l 

Organic Stricture "2 

Organic Stricture, Varieties of. 76 

Organic Stricture, Number of 80 

Otis, (F. N.) Remarks on Urethrisimus 58 

" " Multiple Stricture, Case of 81 

" " Views en the Location of Stricture 84 

" " On Urethal Friction in its Relation to Stricture 99 



33 2 INDEX. 

Otis, (F. N.) Urethra meter 12 n 

Bulb Sounds \2.\ 

Scale of Measurement of Urethra !22 

Remarks on Relation of Gleet to Penile Stricture 142 

Endoscopic Tube -^77 

Dilating Urethrotome 219 

Curved Urethrotome 220 

Diagrona' 225 

Measurement of Penis and Urethra prior to Operation 222 

Olivary Bougies 168 

Operative Treatment of Stricture 213 

Penis, Sections of. -JO 

Prostatic Urethra 2 2 

Section of 3 3 

' " Sinus 3 4 

Follicles !.!!... ...'".: ...". 14 

" " Immunity of from Stricture........ 89 

Perineum, Superficial Fascia of 18 

" Deep Fascia of. 22 

" Diagrammatic Section of 23 

" Vertical Section of. 25 

Plus Conditions of Stricture 50 

Pathological Localization of Stricture 90 

Piffard (H. G.) Meatometer 123 

Piffard (H. G.) Meatatome 123 

Prognosis of Stricture 128 

Penile Stricture, Prognosis of 149 

Peyrani, Effect of Section of Sympathetic Nerves en Renal Secretion 186 

Palmer (E. R.) Boric Arid as a Urinary Antiseptic , 198 

Prostate, Inflammation of, from Dilatation 210 

Prostate, Hypertrophy of, Complicating Stricture 321 

Penis, Curvature of. Following Urethrotomy 225 

Permanency of Result of Urethrotomv 229 

Perineal Section 245 

Perineal Section with a Guide 246 

Perineal Section without a Guide 249 

P rineal Fistulae 312 

Prince (David) Method of Electrolysis 264 

Puncture of the Bladder per rectum 282 

Puncture of the Bladder above the pubes 284 

Peri-urethral Suppuration 304 

Peri-urethral Suppuration, Treatment of. 306 

Pyelitis from Stricture 324 

Rifling of the Urethra.. 17 

Resilient Stricture 157 

Recurrent Stricture 157 

Renal Disease, Relation of, to Urinary Fever 185 

Remote results of Urethrotomy 229 

Retention of Urine 278 

Retention of Urine. Treatment of. 280 

Rupture of Bladder 301 

Recto -urethral Fistula 311 

Spongy Urethra 8 

Sinus Pocularis 14 

Sinuses cf Morgagni 14 

Spasm of Cut-off Muscle 22 

Selection of Instruments 35 

Size of Instruments 35 



index. 333 

Scaling of Instruments 37 

Scale Plates 38 

Stricture, Definition of. 48 

" Varieties of. 48 

" Causes of. 48 

Conditions Producing 48 

Spasmodic 50-66-69 

" Spasmodic. Relation of to Cut-off Muscle 51 

Congestive 50-70 

Inflammatory 50-70-71 

Smith (H.) Location of Stricture 84 

Sands (H. B.) Casts of Normal Urethra 94 

Summary of Treatment of Stricture 162 

Systematic Dilatation of Stricture 165 

Sudden Death During Operation upon Urethra 192 

Syrae, Operation of Per neal Section 246 

Subcutaneous Division of Stricture 254 

Supra-pubic Puncture 284 

Seminal Vesicles, Inflammation of, Complicating Stricture 322 

Scrotal Fistulae 312 

Szymanowski Operation for Urethral Fistula ..: 318 

Szymanowski Operation for Urethral Fistula, Illustration ol i 316 

Stone in the Bladder as a Complication of Stricture 320 

Triangular Ligament ■ 22 

Triangular Ligamtnt, Illustration of 22 

Triangular Ligament, Contents of. 22 

Thompson (Sir. H.) Normal Urethral Curve 28 

" " On the Location of Stricture 84 

" Heredity in Stricture 112 

" Divulsor for Stricture 214 

" " Cure of Recto- Urethral Fistula by Position 311 

Transverso-Urethral Muscle 21 

Tortuous Stricture 79 

Toxaemia from Stricture 118 

Treatment of Stricture 135 

Treatment of Stricture, Summary of. 162 

Treatment of Meatus 139 

Treatment of Penile Stricture 140 

Tortuous Complicated Stricture 

Urethra, Anatomy of 3 

Functions of 3 

Length of 4 

" Curves of 4 - 27 

" Variation in Length of * 

" Vertical Section of. 5 

" Divisions of ® 

" Spongy Portion of 8 

Bulb of. 8 

" Section Through Spongy Portion of 9 

" Membranous Portion of. H 

Glands of. 14 

" Instrumentation of 30 

Stricture of. 16 

Rifling of 17 

Muscles of. 20 

Uterus Masculinus 

Urethrismus 

Untoward Effects of Dilatation 18 ° 



Urethral Fever. 



180 



334 INDEX. 

Urethral Fever, Forms of. 182 

Urethrotome, Varieties of. 218 

" Gouley's 218 

" Maisonneuve's 218 

" Civiale's 219 

" Otis' 219 

" Otis' Curved 220 

*' Otis' Diagonal 225 

Urethrotomy, Internal, Operation of 221 

" Untoward Effects of. 225 

" Curvature of Penis from 225 

" After Treatment in 227 

" Permanency of Result of. 229 

" Remote Effects of. 229 

" Personal Experience in 230 

Cases Showing Permanency of Results 231 

" External 245 

" Subcutaneous 254 

Urine, Retention of 278 

Urine, Infiltration of.? 286 

Urinary Fistula 306 

Urinary Fistula, Treatment of. 309 

Urethroplasty 312 

Veru montanum 13 

Veru montanum, Paralysis of. 13 

Varieties of Stricture 48 

Varieties of Organic Stricture 76 

Van Buren (Wm. H.), Sound of. 169 

Weiss (F. D.) Bougie a Boule 122 

Weir (R. H.) Meatascope 177 

Weir (R. H.) Renal Disturbance Following Gastro-Enterotomy 189 

Wheelhouse, Operation of Perineal Section 252 



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ANDREWS, EDMUND, arid E. WYLL1S ANDREWS, 

M. D„ LL. D., A. M. 9 M. D. 

Professor of Clinical Surgery, Northwestern Uni- Professor of Clinical Surgery, Northwestern Uni' 
versity Medical School, Surgeon of Mercy versity Medical School^ Surgeon oj Mercy 

Hospital, etc. Hospital, and Michael Reese Hospital, etc. 

Rectal and Anal Surgery. With a full description of the secret methods of 
the itinerant specialists. Third Edition. Revised and enlarged, with illustration™ 
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$1.50 net 
BLACK (G. V.), M. 2)., DD. S., 

Professor of Pathology, Northioestern University Dental School, Chicago. 

A Study of the Histological Characters of the Periosteum and Peridental 
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BELFIELD ( WM. T.) 9 M. D. 

Genito-Urinary Surgery, with Cystoscopy. One volume, 8vo., with illustra- 
tions, including colored plates of morbid conditions of the bladder as seen by 
means of the Cystoscope. In press. 

FOTHERGILL, J. MILLNER, M. D., 

Member Royal College of Physicians, London; Senior Assistant Physician to the City of Lon- 
don Hospital for Diseases of the Chest {Victoria Park); Late Assistant Physician to the West 
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Indigestion and Biliousness. " What is one man's meat is another's poison." 
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THE WORKS OF I. J. M. GOSS 9 M. D„ 

Late Professor of Materia Medica, now Professor of the Practice of Medicine in the College 
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GRADLE, HENRY, M.D., 

Late Professor of Physiology in the Chicago Medical College ; Oculist to Michael Reese Hospital. 

Bacteria and the Germ Theory of Diseases. Eight lectures delivered at the 

Chicago Medical College. One volume, 8vo., 219 pages. Cloth, $1.00. 

GRADLE (HENRY). M. D., 

Late Professor of Physiology, Chicago Medical College. 

Lectures on General Etiology. 12mo. Paper, $0.25. 

GUNN, MOSES, M. D., LL. D. 

Late Professor of Surgery in Rush Medical College, Chicago. 

Memorial Sketches by his wife, with extracts from his letters and eulogistic 
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HAYES, PLYM S. 9 A. M., M. D., 

Late Professor of Chemistry and Toxicology, Women'' s Medical College; Professor of Ana- 
lytical Chemistry, Chicago College of Pharmacy ; Professor of Gynaecology and of Electro- 
Therapeutics, Chicago Policlinic, etc., etc. 

Electricity and the Method of its employment in Removing Superfluous 
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Stricture of the Urethra. One volume, 8vo., 330 pages. Seven full page colored 
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Varicocele and its Treatment. One volume, 12mo., 128 pages. With numer- 
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LYM AN, HESBY M„ A. M., M. D. 9 

Professor of the Principles and Practice of Medicine in Rush Medical College, Chicago. 
Insomnia and Other Disorders of Sleep. One volume, 12mo., 238 pages. 

Cloth, $1.50. 
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Professor of Gynaecology at the Post-Graduate Medical School, Chicago ; Attending Surgeon 
Women's Hospital of Chicago ; Gynaecologist to Charity and Post-Graduate Hospitals ; Mem- 
ber of the American Gynaecological Society, and the Chicago Gynaecological Society, etc., etc. 

Electricity in the Diseases of Women and Obstetrics. One volume, 8vo. 
xiv+280 pages; 84 illustrations. Second Edition. Cloth, $2.00 net. 

MITCHELL (CLIFFORD), A. M. 9 M. D., 

Professor of Renal Diseases in Chicago Homoeopathic Medical College. 
A Clinical Study of Diseases of the Kidneys. Including systematic chemical 
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MITCHELL (CLIFFORD), A. M., M. D., 

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Dental Chemistry and Metallurgy. Being the I'hird Edition of the Dentist's 
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Adopted by the American Association Dental Faculties as a text-book of 
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Professor of Pharmacy and Director of the Pharmaceutical Laboratory, Northwestern Uni- 
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A Manual of Weights and Measures. Including principles of metrology; 
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*** The adoption of the metric system in the forthcoming edition of the U. S. 
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ough knowledge of that system a greater necessity than before. 

OLDBERG (OSCAR), PHARM. D. 

An Outline of a Course of Study in Practical Pharmacy. (As pursued in 
the Northwestern University School of Pharmacy.) Intended as a guide for 
students. Second Edition. 12mo., 112 pages, interleaves. Cloth, $1.25 net. 

OLDBERG (OSCAR), and LONG (JOHN H.), 

PHARM. D., SC. D. 9 

Professor of Pharmacy and Director of the Professor of Chemistry and Director of Chem- 

Pharmaceutical Laboratory, Northwestern ical Laboratory of the Northwestern Uni- 

University School of Pharmacy ; Member of versity Medical School and School of Phar- 

Committee for Revision of the Pharmaco- macy. 
poeia of the United States. 

A Laboratory Manual of Chemistry, Medical and Pharmaceutical. Contain- 
ing experiments and practical lessons in inorganic synthetic work; formula? for 



over three hundred preparations, with explanatory notes; examples in quantitative 
Determinations and the valuation of drugs, and short systematic courses in quali- 
tative analysis and in the examination of urine. With original illustrations. 
Second Edition. 8vo., 457 pages, 5 full-page plates, and numerous illustrations in 
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*** This is the only laboratory manual of chemistry based upon the Pharma- 
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home study. 

PARRE1DT, JUL, 

Dental Surgeon to the Surgical Policlinic at the Institute of the University of Leipsic. 

A Compendium of Dentistry. For the use of medical practitioners and stu- 
dents. Authorized translation by Louis Ottopy, DD. S., with notes and additions 
by G. V. Black, M. D., DD. S., Professor of Pathology Northwestern University 
Dental School. 8vo., 229 pages. Profusely illustrated. Cloth, $1.50 



THE WORKS OF NICHOLAS SENN, PH. D., M. D., 

Professor of Practice of Surgery and Clinical Surgery in Bush Medical College ,* Attending 
Surgeon Presbyterian Hospital. 

I: Experimental Surgery. Contents — Fractures of the Neck of the Femur, with 
special reference to Bony Union after Inter-Capsular Fracture. II. Experimental 
Researches on Cicatrization in Blood Vessels after Ligature. III. An experi- 
mental and clinical study of Air-Embolism. IV. The Surgery of the Pancreas, as 
based upon experiments and clinical researches. V. An experimental contribution 
to Intestinal Surgery, with special reference to the Treatment of Intestinal 
Obstruction. VI. Rectal Insufflation of Hydrogen Gas as an Infallible Test in the 
Diagnosis of Visceral Injury of the Gastro-Intestinal Canal in Penetrating Wounds 
of the Abdomen. Complete in one handsome volume, 8vo. 

Cloth, $5.00; half morocco, $6.00. 



The different parts of this volume have been 
published from time to time in Transactions of 
the American Surgical Association, and in peri- 
odicals not readily accessible to the majority 



of the medical profession. In response to a verj 
general demand they have been revised by the 
author and published in a convenient sized vol- 
ume, carefully indexed. 



II. Intestinal Surgery. Contents — The Surgical Treatment of Intestinal Ob- 
struction. II. An experimental contribution to Intestinal Surgery, with special 
reference to the Treatment of Intestinal Obstruction. III. Rectal Insufflation of 
Hydrogen Gas as an Infallible Test in the Diagnosis of Visceral Injury of the 
Gastro-Intestinal Canal in Penetrating Wounds of the Abdomen. IV. Report of 
Cases. One handsome volume, 8vo. Cloth, $2.50 



The most striking, the most valuable of 
Senn's original conceptions and applications 
are: 

1. The uses of gaseous enemeta both for di- 
agnostic and therapeutic purposes. 

2. Lateral approximation by decalcified bone 
plates. 

3. The application of omental grafts in ab- 
dominal surgery ; and 

4. The mechanical irritation of peritoneal 
surfaces between which it is desired that ad- 
hesion should take place. 



The greatest value of Senn's work is its sug- 
gestiveness. He has set surgeons in all coun- 
tries to thinking and planning. His methods 
as such may none of them be permanent, but he 
has given an impetus to abdominal surgery the 
outcome of which none can foresee, but which 
is full of promise. He is in the very van of 
progress, a leader who is not infallible, but who 
has e&rned by hard work and ability the envi- 
able place he holds in the scientific world.— The 
American Journal of Medical Science. 



HARLAN (A. W.), I>D. S., M. D. 

A Register for Recording Operations on the Natural Teeth. A simple and 
complete method for keeping accounts of dentists. One volume, oblong (9*^x12 
inches), bound in half Russia, round corners. Prices, 350 pages, $3.50; 500 pages, 
$4.50, net. Each with diagram of the teeth printed in red, 50c extra. 



THE UNIVERSAL LIQUOR REGISTER. 

Adapted to the laws of all states requiring registrations of sales of liquors. 
Second edition, one volume, 4to. (6%x8^ inches), $1.00 net. 



THE UNIVERSAL POISON REGISTER. 

Uniform with the Universal Liquor Register. 



Price, $1.00 net. 



JUST READY. 

STRICTURE OF THE URETHRA 



•BY- 



G. FRANK LYDSTON, M.D. 

PROFESSOR OF THE SURGICAL DISEASES OF THE GENITO-URINARY ORGANS AND VENEREAL 
DISEASES IN THE COLLEGE OF PHYSICIANS AND SURGEONS, CHICAGO; SURGEON- 
IN-CHIEF OF THE GENITO-URINARY AND VENEREAL DEPARTMENT OF 
THE WEST SIDE DISPENSARY; FELLOW OF THE CHICAGO ACAD- 
EMY OF SCIENCES AND OF THE SOUTHERN SURGICAL 
AND GYNAECOLOGICAL ASSOCIATION, ETC. 

The object of this work is to present the modern methods of treatment of Strict- 
ure. The Chapter on Urethrotomy is especially full and practical. A Chapter devoted 
to Electrolysis is a fair presentation of the limitation of treatment by Electricity. The 
author's views on strictures of large calibre and their relation to Urethral Pathology 
are very fully and clearly presented and offer a reasonable ground of reconciliation of 
conflicting opinions regarding the importance of these lessons which have been the sub- 
ject of so much animated discussion and controversy. 

Complete in one handsome octavo volume of about 150 pages. Profusely illus- 
trated with seven full page colored engravings and numerous wood cuts in the text. 

Price, Cloth, $3.00 Net. 



BY THE SAME AUTHOR 

VARICOCELE 

AND ITS TREATMENT. 

One Handsome Volume, Illustrated, 8vo., Cloth, $1.25. 

From Oaillard's Medical Journal, March, '93. 

" This Monograph presents a concise but at the same time a more comprehensive 
review of the subject of Varicocele than is to be found in any other place. There is no 
other complete treatise on the subject *** The chief interest to the general practi- 
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ence are studied and described. More than twenty methods of operation are described. 
The general appearance and make up of the book is worthy of note and reflects decided 
credit upon the publisher." 



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SECOND EDITION NOW READY. 



ELECTRICITY 



IN 

Diseases of Women and Obstetrics 

BY 

FRANKLIN H. MARTIN, M.D., 

Professor of Gynecology in the Post-Graduate School of Chicago ; Surgeon to the Woman's 

Hospital ; Gynaecologist to the Charity and Post-Graduate Hospitals ; 

Fellow of the American Gynaecological Society. 



The present edition is enlarged and revised. Four new chapters have 
been added : Chapter XXX. — General Galvanization and General Faradi- 
zation. Chapter XXXI. — The Electric Bath. Chapter XXXII.— Static 
Electro-therapeutics ; and Chapter XXXIII. — Summary of Treatment of 
General Diseases. Thus, while the book purports to be a work on Electricity 
as applied to Diseases of Women and Obstetrics, these added chapters give 
it a wider scope, inasmuch as they give a general summary of all diseases for 
which electricity is applicable, except those coming under special heads, as 
diseases of the eye and ear, and those diseases peculiar to the male. The 
chapter on rectal diseases has been revised by my friend, Dr. j. B. Bacon, 
and new matter on the treatment of haemorrhoids added. 



ANNOUNCEMENT OF THE FIRST EDITION. 

This is designed as a modern Theoretical and Practical Text-Book on the subject of Electricity in 
Diseases of Women and Obstetrics. 

The theoretical portion of the work, which includes the Physics of Electricity, is none the less 
practical because of being theoretical and technical. No physician now can afford to handle this 
powerful therapeutic agent without understanding its principles. An effort has been made to accom- 
plish this part of the work by simple illustrative experiments and examples, rendering the subject easy 
to comprehend without perplexing the student with complicated mathematical demonstrations. 

Features of this portion of the work are the chapters which thoroughly handle the subject of 
measurement, the storage-battery, the utilization of the electric light current, the cautery battery, the 
dynamo and the rheostat. 

The strictly practical portion of the work— Part Second— treats exhaustively and in detail all 
Diseases of Women and Obstetrical complications which have been found by experience to be bene- 
ficially influenced by Electricity in any form. The Apostoli treatment in all its details and modifications 
is given its deserved space with a large number of clinical reports which demonstrate the value of the 
remedy as well as the danger to be avoided in its employment. • 

The subjects of Amenorrhcea, Dysmenorrhcea, Stricture of the Urethra and Rectum, Metritis, 
Endometritis and Cancer, are dealt with at length. 

The Obstetrician will find chapters on Extra-uterine Pregnancy, Vomiting in Pregnancy, Post 
partum Haemorrhage and Abortion. 

One of the features of the work is an exhaustive chapter on Hystero-Neurasthenia, with a descrip- 
tion of the Weir-Mitchell Treatment. 

The Work is Profusely Illustrated with many New and Original Drawing. 



Complete in One Handsome Octavo Volume, Cloth. Price, $2.00 Net, Postpaid. 



THE W. T. KEENER COMPANY, 

Medical Importers, Booksellers and Publishers, 

96 Washington Street, CHICAGO. 



THE WORKS OF 

Nicholas Senn, Ph. D., M. D, 

Professor of Practice of Surgery and Clinical Surgery in Rush Medical College ' 
Attending Surgeon Presbyterian Hospital. 



I. 



Experimental Surgery. 



Contents -Fractures of the Neck of the Femur, with special reference to Bony Union after Intra- 
capsular fracture. II. Experimental Researches on cicatrization in Blood Vessels after Liga- 
ture. III. An experimental and clinical study of Air-Embolism. IV. The surgery of The Pan- 
creas as based upon experiments and cl nical researches. V. An experimental contribution to 
Intestinal Surgery, with special reference to the Treatment of Intestinal Obstruction. VI. Rec- 
tal Insufflation of Hydrogen Gas as an Infallible Test in the Diagnosit of Visceral Injury of the 
Gastro-lntestinal Canal in Penetrating Wounds of the Abdomen. 

Complete in One Handsome Volume, 8vo. Cloth, $5.00; Half Mor. $6.00. 

The different parts of this volume have been published from time to time in Transactions of The 
American Surgical Association, and in periodicals not readily accessible to the majority of the Medical 
Profession. In response to a very general demand they have been revised by the Author and published 
in a convenient sized vclume, carefully indexed. The Edition is limited, a few copies only remaining 
unsold. 



Intestinal Surgery. 



II. 



Contents— The Surgical Treatment of Intestinal Obstruction. II. An experimental contribution 
to Intestinal Surgery with spec al reference to the Treatment of Intestinal Obstruction. III. Rectal 
Insufflation of Hydrogen Gas as an Infallible Test in the Diagnosis of Visceral Injury of the Gastro- 
intestinal Canal in Penetrating Wounds of the Abdomen. IV. Report of cases. 

One Handsome Volume, 8vo. Cloth, $2.50. 



From The American Journal of Medical Science. 

In a work characterized not only by careful arrangement and clear exposition, but also by a 
patience of research and an originality of conception which promise the author a lasting fame in the 
annals of surgery, there must necessarily be much to praise; and again, it is a poor book in which 
there is nothing to criticise. 

The most striking, the most valuable of Senn's original conceptions or applications are: 

1. The uses of gaseous enemata both for diagnostic and therapeutic purposes. 

2. Lateral approximation by decalcified bone plates. 

3. The application of omental grafts in abdominal surgery; and, 

4. The mechanical irritation of peritoneal surfaces between which it is desired that adhesion 
should take place. 

The value of all these methods has been experimentally proven, and they have been successfully 
. pplied by Senn and by other surgeons who have carefully reviewed his work. It is difficult to determ- 
i le whether the enthusiasm and the confidence with which he writes should be praised or condemned. 
After completing his book, the surgeon lays it down with the conviction that at last the difficulties and 
dangers of abdominal work have been overcome, that the definite rules of operative procedure are estab- 
lished, that this branch of surgical knowledge is completed from Alpha to Omega. In the toil and 
travail of an obscure case there may be a tendency in the mind of the operator to resent this "cock- 
sure" style which filled his mind with such joyous anticipation, but when one or another of Senn's bril- 
liant expedients has finally Drought him to a successful termination, he may be disposed to look more 
forgivingly on this fault. 

The greatest value of Senn's work is its suggestiveness. He has set surgeons in all countries to 
thinking and planning. His methods as such may none of them be permanent, but he has given an 
impetus to abdominal surgery the outcome of which none can foresee, but which is full of promise. He 
is in the very van of progress, a leader who is not infallible, but who has earned by hard work and ability 
the enviable place he holds in the scientific world. 

The gaseous enemata which he advocates as an infallible test in the diagnosis of wounds of the 
gastro-intestinal canal will probably not be found to sustain this claim, yet no one can deny the im- 
mense value of this method, nor withhold admiration for the genius which prompted its application. 
Finally, his book should be duly appreciated, and no higher tribute can be paid to its value than that it 
stimulates the surgeon to better thought and better work. 



THE W. T. KEENER COMPANY, 

Medical Publishers, Importers and Booksellers, 
96 Washington St., Chicago. 



NOW REAbY. 



INDIGESTION and BILIOUSNESS. 

BY J. MlLNER FOTHERGILL, M. D. , 

Member of the Royal College of Physicians of London ; Senior Assistant to the City of London Hospital 

for Diseases of the Chest (Victoria Park) ; late Assistant Physician to the West London 

Hospital ; Associate Fellow of the College of Physicians of Philadelphia. 



"Dr. Fothergill's writings always command attention: they are sprightly and full of instructive 
facts, drawn mostly from his own large experience. This volume is written from a physiological stand- 
point, and begins with an account of natural digestion, by way of introduction or antithesis to the main 
topic of the book. As the liver is the great storehouse of supplies for the use of the system, four chap- 
ters are devoted to its functions and their disturbances. In referring to the influence of mental strain 
and worry, Dr. Fothergill says: ' Talking one day with Mr. Van Abbott, whose biscuits for diabetics 
have such a well-deserved renown, I asked him, "' Who are your diabetics mostly?" The reply was very 
significant. " Business men, comparatively old and gray for their years ; men who look as if they had a 
deal on their minds." This was the response. It stands in suggestive relationship to the fact of acute 
diabetes being set up by shock or other mental perturbation, or of its artificial production by the punc- 
ture of the floor of the fourth ventricle.' The whole book is practical and interesting reading." 

" The relation of digestion to habits of life, to methods of living, and to the perfect nutrition of the 
body, are treated in a masterly manner, and abound in practical hints of the greatest possible utility to 
the practicing physician. Altogether, the work is a remarkably comprehensive study of a subject which 
is too little understood by the majority of medical men." — New York Medical Record. 

One Volume, 1 2mo., Cloth, $2.25. 

Mailed postpaid on receipt of price. 



INSOMNIA 



-AND- 



OTHER DISORDERS OF SLEEP. 

By Henry M. Lyman, A.M., M.D., 

Professor of Physiology and Diseases of the Nerves in Rush Medical College. 

Professor of Theory and Practice of Medicine in the Woman's Medical College. 
Physician to Presbyterian Hospital of Chicago. 



CONTENTS: 

I. — Nature and Cause of Sleep. II.— Insomnia or Wakefulness. III. — Remedies for 
Insomnia. IV.— Treatment of Insomnia. V.— Dreams. VI.— Somnam- 
bulism. VII. — Artificial Somnambulism or Hypnotism. 



'Insomnia and Other Disorders of Sleep,' by Dr. Henry M. Lyman (Chicago: W. T. Keener), is 
a medical book whose matter and style carry it into the higher grades of literature. It represents 
thought»and knowledge, and to students interested in psychical research the last half of the book should 
be useful and attractive. The first half is limited in its adaptation to practicing physicians. — The 
Nation. 

It is pleasant to find a book which is clearly the result of a natural literary effort and the author's 
fondness for his theme— a book not written to "supply a long-felt want " or " to fill an existing gap." 
Dr. Lyman's is such a one, and shows that the subject of which he writes has been a pleasant study. It 
is readable and full of interest, and is quite up to the times, which is important, as the last work upon 
Sleep, a very good one by the way, was written by Dr. Hammond nearly fifteen years ago. — The New 
York Medical Journal. 

Those who would like to acquaint themselves with what science has to say on these topics, and 
learn how they are regarded by the wisest students of the age, may turn with profit to the pages of this 
book. The author is well known, not only as a skilled physician and accomplished teacher, out as one 
of the most polished writers of the American Medical Press. — Philadelphia Medical and Surgical 
Reporter. 

One Volume, 1 2mo., Cloth, $1 .50. 

THE W. T. KEENER COMPANY, 

Medical Importers, Booksellers and Publishers, 

96 Washington Street, CHICAGO. 



THIRD EDITION NOW READY. 

"The book will be found useful, not only as a Text Book under a 
teacher, but also for self-study." — The American Druggist. 



A LABORATORY MANUAL OF 

CHEMISTRY, 

MEDICAL AND PHARMACEUTICAL, 

CONTAINING 

Experiments and Practical Lessons in Inorganic Synthetical Work ; Formula for Over 
Three Hundred Preparations, with Explanatory Notes; Examples in Quantitative 
Determinations and the Valuation of Drugs; and Short Synthetical Courses in 
Qualitative Analysis and in the Examination of Urine. 

By Oscar Oldberg, Pharnv D., 

Professor of Pharmacy and Director of the Pharmaceutical Laboratories in the Northwestern University 

School of Pharmacy. 

By John H. Long, Sc. D., 

Professor of Chemistry and Director of the Chemical Laboratories of the Northwestern University 

Medical School and the School of Pharmacy. 

WITH ORIGINAL ILLUSTRATIONS. 

Our object in preparing this manual was to provide in convenient form a sufficient number of 
suitable lessons in laboratory work, and at the same time to embody in the book the facts of inorganic 
chemistry most important to pharmacy and medicine, It contains experiments intended to familiarize 
the student with the properties of the principal elements, lessons in synthetical chemistry, a systematic 
course in qualitative analysis, examples in quantitative determinations, including the official methods 
of assay for a few important drugs, and a short chapter on the chemical and microscopical examination 
of urine. 

Among the lessons in Part II will be found the working formulae of the pharmacopoeias for many 
of the preparations. - ' 

Students pursuing synthetical work without an instructor can successfully and with benefit make 
most of the pharmaceutical preparations included in the Second Part, with the aid of the explanatory 
notes it contains. For purposes of practice the quantities of materials operated upon may, of course, 
be small, and the outfit of apparatus limited to the list given in the appendix. The proportions of the 
materials are stated, sometimes in part by weight, and sometimes in different quantities expressed in 
terms of the metric system, which will afford useful practice in the application of both forms. 

The portions devoted to analytical methods are necessarily much condensed, but believed to 
contain all that is essential in a work of this character. — The Preface. 

A LABORATORY MANUAL OF CHEMISTRY. 

OPINIONS OF THE PRESS: 

" The book cannot fail to be a serviceable one both to students in college^ and to those unable to 
avail themselves of the advantages of a school. The appendix contains, in addition to useful tables for 
reference, a list of reagents and of the apparatus required for carrying out the experiments described." 
— The Pharmaceutical Et a. 

"Although there are chemistries without number, this is the first laboratory manual adapted to 
our Pharmacopoeia that has been offered to American Pharmacists. * * * One important and com- 
mendable feature noticeable throughout the entire book is the close adherence to the most approved 
chemical nom aclature, which, with the excellent typographical work, makes it far superior to the 
English books of the same class. * * * The descriptions and cuts of chemical apparatus will be 
found useful to those studying without a teacher. The tables make it a very convenient book of refer- 
ence." — The Polyclinic. 

" As a whole we believe this book to be worthy of strong recommendation ; and we heartily 
congratulate the authors and the publishers upon its contents and appearance."— The Medical and 
Surgical Reporter. 

" In the arrangement of this work, the authors have steadily kept practice to the front, theory 
taking a second place. * * * * The Pharmaceutical student will find it a convenient laboratory 
manual in which all the more important facts of inorganic chemistry are well set forth."— The Druggist 
Circular. 

" It contains all that any medical student can hope to learn, with directions how to do it, and very 
much more than many teachers of medical chemistry know. IT IS THE LABORATORY MANUAL 
FOR THE STUDENT."— Journal of the American Medical Association. 

One Volume, 8vo., Cloth, $3.50 Net. 

Mailed postpaid on receipt of the price. 

Specimen Page, Table of Contents, Etc., Sent Free upon Application. 

THE W. T. KEENER COMPANY, 

Medical Publishers, booksellers and Importers, 

96 Washington Street, CHICAGO. 



THIRD EDITION. (SIXTH THOUSAND) Now Ready. 



RECTAL AND ANAL SURGERY. 

With Description of the Secret Methods of the Itinerant Specialists. 

By EDMUND ANDREWS, M.D., LL. D., 

Professor of Clinical Surgery, Chicago Medical College ; Surgeon to Mercy Hospital, etc. 

EDWARD WYLLYS ANDREWS, A.M., M.D., 

Professor of Clinical Surgery, Chicago Medical College; Surgeon to Mercy Hospital, etc. 

Third Edition, Revised and Enlarged. One Volume, 8vo. Cloth, $1.50, net 
With Illustrations and Formulary, Profusely Illustrated,, 

The rapid sale of the first and second editions of this manual has compelled the 
preparation of the third much sooner than was anticipated. Advantage has been 
taken of the opportunity thus given to re-write and enlarge almost every part of 
the work, and to introduce several new chapters and an Appendix. A few cuts 
have also been added. A chapter has been added upon the Neuroses of the 
Rectum and Anus. Rectal Neuropathy now receives that separate consideration 
which it deserves, a new feature in this Edition. 

Further to make this book a vade mecum in the hands of those who must 
hurriedly turn many books in the intervals of active practice, a compact formulary 
has been prepared, which contains in classified form every prescription in the body 
of the work and a considerable number of others. These are all tried remedies, and 
many of them have the authors' names affixed. 

With this Formulary for reference, the practitioner who has once read the book 
can by almost instantaneous reference secure the necessary details for the treat- 
ment of any given case which is before him. These formulas have been collected 
from a very large number of works in various languages. Over fifty are given, and 
these are nearly all that can be found in a score or more of the best modern treat- 
ises, those being omitted, of course, which are practical repetitions of each other. 

A chapter has also been given to the sacculi Horneri and columns of Morgagni, 
in order more clearly to expose the ridiculous pathology which some have sought 
to connect with these innocent structures. 



From the Post-Graduate, N. Y.: 

"Originally this book of Professor Andrews and his son derived its chief value 
from the thorough exposition of the ways of the travelling quacks who flourished 
with their hypodermic syringes throughout the West. The authors devoted more 
time to these gentlemen than they deserved, with the result of rendering the pro- 
fession fairly conversant with their secrets and methods. By stating plainly and 
concisely what was true in the surgery of the rectum, and comparing it with what 
was false and fraudulent, the book was first written, and from this beginning has 
now reached its third edition. It has grown in scientific value with age. It makes 
no claim to completeness in pathology or research on doubtful points — its size, 
indeed, precludes that — but it claims to be a correct working hand book, embodying 
much useful practical information; and such it is. 

" In this, the last edition, however, a chapter has been added which, as far as it 
goes, raises the status of the work to a much higher plane. We refer to the 
attempt, and successful attempt, here made for the first time at something like a 
complete, scientific classification of the neuroses of the rectum, and we congratulate 
the authors on the result. This chapter alone givf s the work an indisputable place 
in the library of every student of diseases of the rectum." C. B. K. 



THE W. T. KEENER COMPANY, 

Medical Publishers* Importers and jBooksellers, 
96 Washington Street. CHICAGO, ILL. 



